(a) The department has authority to conduct examinations
of HMOs under Insurance Code Chapters 401 (concerning Audits and Examinations)
and 751 (concerning Market Conduct Surveillance), and Insurance Code §843.156
(concerning Examinations) and §843.251 (concerning Complaint
System Required; Commissioner Rules and Examination), and such examinations
are subject to §7.83 of this title (relating to Appeal of Examination
Reports). The department will conduct examinations to determine the
financial condition (financial exams), quality of health care services
(quality of care exams), or compliance with laws affecting the conduct
of business (market conduct exams).
(b) The following documents must be available for review
at the HMO's office located within Texas or at a location approved
by the department under Insurance Code §803.003 (concerning Authority
to Locate Out of State):
(1) administrative: policy and procedure manuals; physician
and provider manuals; enrollee materials; organizational charts; key
personnel information, for example, resumes and job descriptions;
and other items as requested;
(2) quality improvement: program description, work
plans, program evaluations, and committee and subcommittee meeting
minutes;
(3) utilization management: program description, policies
and procedures, criteria used to determine medical necessity, and
templates of adverse determination letters; adverse determination
logs, including all levels of appeal; and utilization management files;
(4) complaints and appeals: policies and procedures
and templates of letters; complaint and appeal logs, including documentation
and details of actions taken; and complaint and appeal files;
(5) satisfaction surveys: enrollee, physician, and
provider satisfaction surveys, and enrollee disenrollment and termination
logs;
(6) health information systems: policies and procedures
for accessing enrollee health records and a plan to provide for confidentiality
of those records;
(7) network configuration information: as required
by §11.204(19) of this title (relating to Contents) demonstrating
adequacy of the physician, dentist, and provider network;
(8) executed agreements, including:
(A) management services agreements;
(B) administrative services agreements; and
(C) delegation agreements;
(9) executed physician and provider contracts: copy
of the first page, including form number, and signature page;
(10) executed subcontracts: copy of the first page,
including the form number, and signature page of all contracts with
subcontracting physicians and providers;
(11) credentialing: credentialing policies and procedures
and credentialing files;
(12) reports: any reports submitted by the HMO to a
governmental entity;
(13) claims systems: policies and procedures and systems
or processes that demonstrate timely claims payments, and reports
that substantiate compliance with all applicable statutes and rules
regarding claims payment to physicians, providers, and enrollees;
(14) financial records: financial information, including
statements, ledgers, checkbooks, inventory records, evidence of expenditures,
investments and debts; and
(15) other: any other records requested by the department
to demonstrate compliance with applicable statutes and rules.
(c) The department will conduct quality of care exams
as follows:
(1) Entrance conference. The examination team or assigned
examiner may hold an entrance conference with the HMO's key management
staff or their designee before beginning the examination.
(2) Interviews. Examination team members or the examiner
may conduct interviews with key management staff or their designated
personnel.
(3) Exit conference. On completion of the examination,
the examination team or examiner may hold an exit conference with
the HMO's key management staff or their designee.
(4) Written report of examination. The examination
team or examiner will prepare a written report of the examination.
The department will provide the HMO with the written report, and if
any significant deficiencies are cited, the department will issue
a letter outlining the time frames for a corrective action plan and
corrective actions.
(5) Corrective action plan. If the examination team
or examiner cites significant deficiencies, the HMO must provide a
signed corrective action plan to the department no later than 30 days
from receipt of the written examination report. The HMO's plan must
provide for correction of these deficiencies no later than 90 days
from the receipt of the written examination report.
(6) Verification of correction. The department will
verify the correction of deficiencies by submitted documentation or
by on-site examination.
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