| (a) The commissioner may conduct an examination relating
to a preferred or exclusive provider benefit plan as often as the
commissioner considers necessary, but no less than once every three
years.
(b) On-site financial, market conduct, complaint, or
quality of care exams will be conducted under Insurance Code Chapter
401, Subchapter B, concerning Examination of Carriers; Insurance Code
Chapter 751, concerning Market Conduct Surveillance; Insurance Code
Chapter 1301, concerning Preferred Provider Benefit Plans; and §7.83
of this title (relating to Appeal of Examination Reports).
(c) An insurer must make its books and records relating
to its operations available to the department to facilitate an examination.
(d) On request of the commissioner, an insurer must
provide to the commissioner a copy of any contract, agreement, or
other arrangement between the insurer and a physician or provider.
Documentation provided to the commissioner under this subsection will
be maintained as confidential as specified in Insurance Code §1301.0056,
concerning Examinations and Fees.
(e) The commissioner may examine and use the records
of an insurer, including records of a quality of care program and
records of a medical peer review committee, as necessary to implement
the purposes of this subchapter, including commencement and prosecution
of an enforcement action under Insurance Code Title 2, Subtitle B,
concerning Discipline and Enforcement, and §3.3710 of this title
(relating to Failure to Provide an Adequate Network). Information
obtained under this subsection will be maintained as confidential
as specified in Insurance Code §1301.0056. In this subsection,
"medical peer review committee" has the meaning assigned by Occupations
Code §151.002, concerning Definitions.
(f) The following documents must be available for review
at the physical address designated by the insurer in accordance with §3.3722(c)(12)
of this title (relating to Application for Preferred and Exclusive
Provider Benefit Plan Approval; Qualifying Examination; Network Modifications):
(1) quality improvement--program description, work
plans, program evaluations, and committee and subcommittee meeting
minutes as required by §3.3724 of this title (relating to Quality
Improvement Program) must be available for examinations of an exclusive
provider benefit plan offered under Insurance Code Chapter 1301 in
the commercial market;
(2) 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;
(3) complaints--complaint files and complaint logs,
including documentation and details of actions taken. All complaints
must be categorized and completed in accordance with §21.2504
of this title (relating to Complaint Record; Required Elements; Explanation
and Instructions);
(4) satisfaction surveys--any insured, physician, and
provider satisfaction surveys, and any insured disenrollment and termination
logs;
(5) network configuration information as required by §3.3712
of this title (relating to Network Configuration Filings) demonstrating
adequacy of the provider network;
(6) credentialing--credentialing files; and
(7) reports--any reports the insurer submits to a governmental
entity, including the most recent demographic data provided by the
insurer in accordance with §3.3709 of this title (relating to
Annual Network Adequacy Report).
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| Source Note: The provisions of this §3.3723 adopted to be effective February 21, 2013, 38 TexReg 827; amended to be effective March 30, 2021, 46 TexReg 2026; amended to be effective April 25, 2024, 49 TexReg 2497 |
