Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES
Subchapter KK - EXCLUSIVE PROVIDER BENEFIT PLAN
Section 3.9206 - Quality Improvement and Utilization Management
Universal Citation: 28 TX Admin Code § 3.9206
Current through Reg. 50, No. 13; March 28, 2025
(a) An issuer must establish and maintain procedures to assure that the health care services provided to insureds are rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. These procedures must include:
(1) mechanisms to
assure availability, accessibility, quality, and continuity of care;
(2) an ongoing internal quality improvement
program to monitor and evaluate its health care services, including primary and
specialist physician services, and ancillary and preventive health care
services, in all institutional and non-institutional contexts;
(3) a record of formal proceedings of quality
improvement program activities and a means for maintaining documentation in a
confidential manner. Quality improvement program minutes must be made available
to the commissioner;
(4) a
physician review panel to assist in reviewing medical guidelines or criteria
and to assist in determining the prescription drugs to be covered by the EPP,
if the plan contains a prescription drug benefit;
(5) an adequate patient record system that
will facilitate documentation and retrieval of clinical information for the
purpose of the issuer's evaluation of continuity and coordination of patient
care and assessment of the quality of health care services provided to
insureds;
(6) a mechanism for
making available to the commissioner the clinical records of insureds for
examination and review. Such records are confidential and privileged, and are
not subject to Government Code, Chapter 552, Public Information, or to
subpoena, except to the extent necessary to enable the commissioner to enforce
this title; and
(7) a mechanism for
the periodic reporting of quality improvement program activities to its
governing body, providers, and appropriate organization staff. An issuer is
also subject to the same quality improvement requirements as outlined in §
11.1901 of this title (relating to
Quality Improvement Structure).
(b) An issuer must establish a mechanism for utilizing independent review organizations as outlined in Insurance Code Chapter 4201.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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