| (A) an HMO other than an HMO offering a Children's
Health Insurance Program (CHIP) plan to any current or prospective
group contract holder and current or prospective enrollee of the applicant
under Insurance Code §§843.201 (concerning Disclosure of
Information About Health Care Plan Terms), 843.078 (concerning Contents
of Application), and 843.079 (concerning Contents of Application;
Limited Health Care Service Plan), and §11.1600 of this title
(relating to Information to Prospective and Current Contract Holders
and Enrollees);
(B) an HMO offering a CHIP plan in the form of the
member handbook, for information only, together with a certification
from the HMO that the handbook has been approved by the Texas Health
and Human Services Commission and a copy of the document approving
the handbook;
(19) network configuration information for each of
the HMO's physician or provider networks, including limited provider
networks, along with:
(A) maps for each product type demonstrating the location
and distribution of the physician, dentist, and provider network within
the proposed service area by county, with each specialty represented
in one map that includes the radii mileage requirements described
in §11.1607 of this title (relating to Accessibility and Availability
Requirements);
(B) lists for each product type of credentialed and
contracted physicians, dentists, and individual providers, in an Excel-compatible
format, specifying:
(i) last name;
(ii) first name;
(iii) business address;
(iv) the municipality in which the facility is located
or county in which the facility is located if the facility is in the
unincorporated area of the county;
(v) state;
(vi) county;
(vii) telephone number;
(viii) Texas license number;
(ix) specialty;
(x) name of the HMO contracted facility, including
hospital(s), in which the physician or individual provider has privileges;
(xi) date of last credentialing or recredentialing;
and
(xii) an indication of whether they are accepting new
patients;
(C) lists for each product type of credentialed and
contracted facilities, including hospitals, in an Excel-compatible
format, specifying:
(i) name of facility;
(ii) business address;
(iii) the municipality in which the facility is located
or county in which the facility is located if the facility is in the
unincorporated area of the county;
(iv) state;
(v) county;
(vi) telephone number;
(vii) type of facility;
(viii) name of national accrediting body, if applicable;
and
(ix) date of last credentialing or recredentialing;
(D) for each facility listed under subparagraph (C)
of this paragraph:
(i) create separate headings under the facility name
for radiologists, anesthesiologists, pathologists, emergency department
physicians, neonatologists, and assistant surgeons;
(ii) under each heading described by clause (i) of
this subparagraph, list each preferred facility-based physician practicing
in the specialty corresponding with that heading;
(iii) for the facility and each facility-based physician
described by clause (ii) of this subparagraph, clearly indicate each
health benefit plan issued by the HMO that may provide coverage for
the services provided by that facility, physician, or facility-based
physician group;
(iv) for each facility-based physician described by
clause (ii) of this subparagraph, include the name, street address,
telephone number, and any physician group in which the facility-based
physician practices;
(v) include the facility in a listing of all facilities
and indicate each health benefit plan issued by the HMO that may provide
coverage for the services provided by the facility; and
(vi) the list must list each facility-based physician
individually and, if a physician belongs to a physician group, also
as part of the physician group;
(20) a written description of the types of compensation
arrangements, such as compensation based on fee-for-service arrangements,
risk-sharing arrangements, or capitated risk arrangements, made or
to be made with physicians and providers in exchange for the provision
of or the arrangement to provide health care services to enrollees,
including any financial incentives for physicians and providers; provided
that such compensation arrangements are confidential under Insurance
Code §843.078(l) and not subject to Government Code Chapter 552
(concerning Public Information);
(21) documentation demonstrating that the applicant
will pay for emergency care services performed by non-network physicians
or providers as provided by Insurance Code §1271.155 (concerning
Emergency Care);
(22) a description of the procedures by which:
(A) a member handbook and materials relating to the
complaint and appeal process and the independent review process will
be provided to enrollees in languages other than English, in compliance
with Insurance Code §843.205 (concerning Member's Handbook; Information
About Complaints and Appeals); and
(B) access to a member handbook and materials relating
to the complaint and appeal process and the independent review process
will be provided to an enrollee who has a disability affecting communication
or reading, in compliance with Insurance Code §843.205;
(23) notification of the physical address in Texas
of all books and records described in §11.205 of this title (relating
to Additional Documents to be Available for Review);
(24) a description of the HMO's information systems,
management structure, and personnel that demonstrates the applicant's
capacity to meet the needs of enrollees and contracted physicians
and providers, and to meet the requirements of regulatory and contracting
entities;
(25) a written description of the utilization management
and utilization review program;
(26) the URA name and certificate or registration number
if the applicant performs utilization review under Insurance Code
Chapter 4201 (concerning Utilization Review Agents) and Chapter 19,
Subchapter R, of this title (relating to Utilization Reviews for Health
Care Provided Under a Health Benefit Plan or Health Insurance Policy),
or the URA name and certificate number of the certified URA that will
perform utilization review on behalf of the applicant if the applicant
delegates utilization review;
(27) complaint and appeal procedures, templates of
letters, and logs, including the complaint log, which must categorize
each complaint using the following categories and noting all that
are applicable to the complaint:
(A) quality of care or services;
(B) accessibility and availability of services;
(C) utilization review or management;
(D) complaint procedures;
(E) physician and provider contracts;
(F) group subscriber contracts;
(G) individual subscriber contracts;
(H) marketing;
(I) claims processing; and
(J) miscellaneous; and
(28) documentation of claim systems and procedures
that demonstrates the HMO's ability to pay claims timely and comply
with applicable claim payment statutes and rules.
|
