| (II) review of updated history of professional liability claims in accordance with the verification sources and time limits specified in subparagraph (C)(iii) of this paragraph. (E) The credentialing process for health care facilities shall include the following: (i) evidence of state licensure; (ii) evidence of Medicare certification; (iii) evidence of compliance with other applicable state or federal requirements, e.g., Bureau of Radiation Control certification for diagnostic imaging centers, certification for community mental health centers from the Texas Department of State Health Services or its successor agency, CLIA (Clinical Laboratory Improvement Amendments of 1988) certification for laboratories; (iv) evidence of accreditation by a national accrediting body, as applicable; the network shall determine which national accrediting bodies are appropriate for different types of health care facilities. The network's written policies and procedures must state which national accrediting bodies it accepts; and (v) evidence of on-site evaluation of the health care facility against the network's written standards for participation if the provider is not accredited by the national accrediting body required by the network. (F) The network procedures shall provide for recredentialing of health care facilities at least every three years through a process that updates information obtained for initial credentialing as set forth in subparagraph (E)(i) - (v) of this paragraph. (2) The network or the network's delegated entity shall make all credentialing processes and files available to the department upon request. (b) Site visits for cause. (1) The network shall have procedures for detecting deficiencies subsequent to the initial site visit. When the network identifies new deficiencies, the network shall reevaluate the site and institute actions for improvement. (2) A network may conduct a site visit to the office of any doctor or health care practitioner at any time for cause. The network shall conduct the site visit to evaluate the complaint or other precipitating event, which may include an evaluation of any facilities or services related to the complaint or event and an evaluation of medical records, equipment, space, accessibility, appointment availability, or confidentiality practices, as appropriate. (c) Peer review. The quality improvement program shall provide for a peer review procedure for doctors, as required under the Medical Practice Act, Chapters 151 - 164, Occupations Code. The network shall designate a credentialing committee that uses a peer review process to make recommendations regarding credentialing decisions. (d) Delegation of credentialing. (1) If the network delegates credentialing functions to other entities, it shall have: (A) a process for developing delegation criteria and for performing pre-delegation and annual audits; (B) a delegation agreement; (C) a monitoring plan; and (D) a procedure for termination of the delegation agreement for non-performance. (2) If the network delegates credentialing functions to an entity accredited by one of the national accreditation organizations as described in §10.81(c) of this subchapter (relating to Quality Improvement Program), the annual audit of that entity is not required for the function(s) listed in the accreditation; however, evidence of this accreditation shall be made available to the department for review. (3) The network shall maintain and shall make available for the department to review: (A) documentation of pre-delegation and annual audits; (B) executed delegation agreements; (C) semi-annual reports received from the delegated entities; (D) evidence of evaluation of the reports; (E) current rosters or copies of signed contracts with doctors and health care practitioners who are affected by the delegation agreement; and (F) documentation of ongoing monitoring. (4) Credentialing files maintained by the other entities to which the network has delegated credentialing functions shall be made available to the department for examination upon request. (5) In all cases, the network shall maintain the right to approve credentialing, suspension, and termination of doctors and health care practitioners. |
