(a) The following documents must be provided to the
department on request and available for review at the HCC's office
located within Texas:
(1) administrative: policy and procedure manuals, including
procedures relating to confidentiality; patient materials; organizational
charts; and key personnel information, such as resumes and job descriptions;
(2) quality improvement: program description and work
plan as required by §13.481 of this title (relating to Quality
Improvement Structure for HCCs); and, to support requirements under §13.482
of this title (relating to Quality Assurance and Quality Improvement)
for certified HCCs, program evaluations and meeting minutes for committees
and subcommittees;
(3) utilization management: program description; policies
and procedures; criteria used to determine medical necessity; templates
of adverse determination letters and adverse determination logs for
all levels of appeal, or, for certified HCCs, examples of those letters
and logs; and, for certified HCCs, utilization management files;
(4) complaints and appeals: policies and procedures;
and templates of letters, complaint logs, and appeal logs, or, for
certified HCCs, examples of those letters and logs, including documentation
and details of actions taken;
(5) health information systems: policies and procedures
for accessing patient health records and a plan to provide for confidentiality
of those records in accord with applicable law;
(6) network configuration information: as outlined
in and required by §13.413(e)(2) of this title (relating to Contents
of the Application), demonstrating adequacy of the physician and health
care provider network;
(7) executed agreements, including:
(A) contracts with payors;
(B) management services agreements;
(C) administrative services agreements; and
(D) delegation agreements;
(8) executed participant contracts: copy of the first
page, including the form number, and signature page of individual
and group contracts;
(9) executed subcontracts: copy of the first page,
including the form number, and signature page of all contracts with
subcontracting physicians and providers;
(10) physician and health care provider manuals: current
physician manual and current health care provider manual, which must
be provided to each contracting physician and health care provider,
respectively, and which must contain details of the requirements by
which the physicians and health care providers will be governed;
(11) credentialing documentation: credentialing policies,
procedures, and files that demonstrate compliance with §13.483
of this title (relating to Credentialing);
(12) reporting system: the statistical reporting system
developed and maintained by the HCC that allows for compiling, developing,
evaluating, and reporting statistics relating to the cost of operation,
the pattern of utilization of services, and the accessibility and
availability of services; and, for certified HCCs, reports generated
by the system concerning those components;
(13) claims systems: policies and procedures that demonstrate
the capacity to pay claims timely, if applicable, and to comply with
all applicable statutes and rules; and, for certified HCCs, as applicable,
evidence of timely claims payments and reports that substantiate compliance
with all applicable statutes and rules regarding claims payment to
physicians, health care providers, and patients;
(14) financial records: including statements; ledgers;
checkbooks; inventory records; evidence of expenditures, investments,
and debts; and related bank confirmations necessary to ascertain funding;
(15) compliance or accreditation: records regarding
compliance with applicable statutes and rules or accreditation standards,
including audits or examination reports by other entities, such as
governmental authorities or accrediting agencies;
(16) satisfaction surveys: for certified HCCs only,
patient, physician, and provider satisfaction surveys; and patient
disenrollment and termination logs;
(17) reports: for certified HCCs only, any reports
submitted by the HCC to a governmental entity; and
(18) other documents and information: any records requested
pursuant to Insurance Code §848.153.
(b) The documents listed in this section must be maintained
for at least five years from the anniversary date of the applicable
document's creation.
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