| (a) Where to file application. An insurer that seeks
to offer a preferred or exclusive provider benefit plan must file
an application for approval with the Texas Department of Insurance
as specified on the department's website and use the form titled Application
for Approval of Provider Benefit Plan, which is available at www.tdi.texas.gov/forms.
(b) Filing requirements.
(1) An applicant must provide the department with a
complete application that includes the elements in the order set forth
in subsection (c) of this section.
(2) All pages must be clearly legible and numbered.
(3) If the application is revised or supplemented during
the review process, the applicant must submit a transmittal letter
describing the revision or supplement plus the specified revision
or supplement.
(4) If a page is to be revised, the applicant must
submit a complete new page with the changed item or information clearly
marked.
(c) Contents of application. A complete application
includes the elements specified in paragraphs (1) - (12) of this subsection.
(1) The applicant must provide a statement that the
filing is:
(A) an application for approval; or
(B) a modification to an approved application.
(2) The applicant must provide organizational information
for the applicant, including:
(A) the full name of the applicant;
(B) the applicant's Texas Department of Insurance license
or certificate number;
(C) the applicant's home office address, including
city, state, and ZIP code; and
(D) the applicant's telephone number.
(3) The applicant must provide the name and telephone
number of an individual to be the contact person who will facilitate
requests from the department regarding the application.
(4) The applicant must provide an attestation signed
by the applicant's corporate president, corporate secretary, or the
president's or secretary's authorized representative that:
(A) the person has read the application, is familiar
with its contents, and asserts that all of the information submitted
in the application, including the attachments, is true and complete;
and
(B) the network, including any requested or granted
waiver and any access plan as applicable, is adequate for the services
to be provided under the preferred or exclusive provider benefit plan.
(5) The applicant must provide a description and a
map of the service area, with key and scale, identifying the county
or counties to be served. If the map is in color, the original and
all copies must also be in color.
(6) The applicant must provide a list of all plan documents
and each document's associated form filing ID number or the form number
of each plan document that is pending the department's approval or
review.
(7) The applicant must provide the form(s) of physician
contract(s) and provider contract(s) that include the provisions required
in §3.3703 of this title (relating to Contracting Requirements)
or an attestation by the insurer's corporate president, corporate
secretary, or the president's or secretary's authorized representative
that the physician and provider contracts applicable to services provided
under the preferred or exclusive provider benefit plan comply with
the requirements of Insurance Code Chapter 1301, concerning Preferred
Provider Benefit Plans, and this subchapter.
(8) The applicant, if applying for approval of an exclusive
provider benefit plan offered under Insurance Code Chapter 1301 in
commercial markets, must provide a description of the quality improvement
program and work plan that includes a process for physician review
required by Insurance Code §1301.0051, concerning Exclusive Provider
Benefit Plans: Quality Improvement and Utilization Management, and
that explains arrangements for sharing pertinent medical records between
preferred providers and for ensuring the records' confidentiality.
(9) The applicant must provide network configuration
information, as specified in §3.3712 of this title (relating
to Network Configuration Filings).
(10) The applicant must provide documentation demonstrating
that its plan documents and procedures are compliant with §3.3707(j)-(m)
of this title (relating to Waiver Due to Failure to Contract in Local
Markets) and §3.3708 of this title (relating to Payment of Certain
Out-of-Network Claims).
(11) The applicant must provide documentation demonstrating
that the insurer maintains a complaint system that provides reasonable
procedures to resolve a written complaint initiated by a complainant.
(12) The applicant must provide notification of the
physical address of all books and records described in subsection
(d) of this section.
(d) Qualifying examinations; documents to be available.
The following documents must be available during the qualifying examination
at the physical address designated by the insurer in accordance with
subsection (c)(12) of this section:
(1) quality improvement--program description and work
plan as required by §3.3724 of this title (relating to Quality
Improvement Program) if the applicant is applying for approval of
an exclusive provider benefit plan offered under Insurance Code Chapter
1301, in commercial markets;
(2) utilization management--program description, policies
and procedures, criteria used to determine medical necessity, and
examples of adverse determination letters, adverse determination logs,
and independent review organization logs;
(3) network configuration information as outlined in §3.3712
of this title that demonstrates compliance with network adequacy requirements
described in §3.3704(f) of this title (relating to Freedom of
Choice; Availability of Preferred Providers), and all executed physician
and provider contracts applicable to the network, which may be satisfied
by contract forms and executed signature pages;
(4) credentialing files;
(5) all written materials to be presented to prospective
insureds that discuss the provider network available to insureds under
the plan and how preferred and nonpreferred physicians or providers
will be paid under the plan;
(6) the policy and certificate of insurance; and
(7) a complaint log that is categorized and completed
in accordance with §21.2504 of this title (relating to Complaint
Record; Required Elements; Explanation and Instructions).
(e) Network modifications.
(1) An insurer must file a network configuration filing
as specified in §3.3712 of this title for approval with the department
before the insurer may make changes to network configuration that
impact the adequacy of the network, expand an existing service area,
reduce an existing service area, or add a new service area. If any
insured will be nonrenewed as a result of a service area reduction,
the insurer must comply with the requirements under §3.3038 of
this title (relating to Mandatory Guaranteed Renewability Provisions
for Individual Hospital, Medical, or Surgical Coverage; Exceptions).
(2) In accordance with paragraph (1) of this subsection,
if an insurer submits any of the following items to the department
and then replaces or materially changes them, the insurer must submit
the new item or any amendments to an existing item along with an indication
of the changes:
(A) descriptions and maps of the service area, as required
by subsection (c)(5) of this section;
(B) forms of contracts, as described in subsection
(c) of this section; or
(C) network configuration information, as required
by §3.3712 of this title.
(3) An insurer must file with the department any information
other than the information described in paragraph (2) of this subsection
that amends, supplements, or replaces the items required under subsection
(c) of this section no later than 30 days after the implementation
of any change.
(f) Exceptions. Paragraphs (c)(9) and (d)(3) and subsection
(e) of this section do not apply to a preferred or exclusive provider
benefit plan written by an insurer for a contract with the Health
and Human Services Commission to provide services under the Texas
Children's Health Insurance Program (CHIP), Medicaid, or with the
State Rural Health Care System.
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