| (B) the period that claims and any other obligations
for health care filed with the delegated entity, under this and any
other delegation agreements to which the delegated entity is a party,
have been pending but remain unpaid, divided into categories of 0-to-45
days, 46-to-90 days, and 91-or-more days. The summary must include
aggregate information for all delegation agreements entered into by
the delegated entity and information for the specific delegation agreement
entered into between the parties;
(C) the aggregate dollar amount of claims and other
obligations for health care owed by the delegated entity to any physician
or provider, including estimates for incurred but not reported obligations;
(D) information that the HMO requires in order to file
claims for reinsurance, coordination of benefits, and subrogation;
and
(E) documentation, except for information, documents,
and deliberations related to peer review that are confidential or
privileged under Occupations Code, Chapter 160, Subchapter A, (concerning
Requirements Relating to Medical Peer Review), that relates to:
(i) any regulatory agency's inquiry or investigation
of the delegated entity or of an individual physician or provider
with whom the delegated entity contracts that relates to an enrollee
of the HMO; and
(ii) the final resolution of any regulatory agency's
inquiry or investigation;
(21) a provision relating to enrollee complaints that
requires the delegated entity to ensure that on receipt of a complaint,
as defined in Insurance Code Chapter 843 and other applicable insurance
laws and regulations of this state, a copy of the complaint must be
sent to the HMO within two business days, except that in a case in
which a complaint involves emergency care, as defined in Insurance
Code Chapter 843 and other applicable insurance laws and regulations
of this state, the delegated entity must forward the complaint immediately
to the HMO, provided that nothing in this paragraph prohibits the
delegated entity from attempting to resolve a complaint;
(22) a provision that the HMO, the delegated entity,
and any delegated third party must comply with the provisions of Chapter
22 of this title (relating to Privacy);
(23) a provision identifying an officer of the HMO
as the representative of the HMO for all matters related to the delegation
agreement; and
(24) a provision identifying which party to the agreement
will bear the expense of compliance with each requirement set forth
in this subsection, including the cost of any examinations performed
under this subchapter.
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