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Health Maintenance Organization (HMO) FAQs

Credentialing Application

Network Availability

Utilization Review Agents

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Credentialing Application

Q. Where do I send the credentialing application?
A.
Send the credentialing application to the appropriate entity/carrier through which you wish to be credentialed.

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Q. Are all providers required to complete the credentialing form?
A.
  TIC §1452.052 requires the commissioner to prescribe a standardized form for the verification of the credentials of a physician, advance practice nurse, or physician assistant. The Texas Standardized Credentialing Application is located on TDI's website, at: http://www.tdi.texas.gov/forms/form9credential.html.

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Network Availability

Q. How does an HMO deliver care?
A.
An HMO delivers care by providing or arranging for health care services directly or indirectly through contracts and subcontracts with physicians, providers, and/or other HMOs.

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Q. What determines whether an HMO has an adequate health care delivery system?
A.
All covered health care services that are offered by the HMO shall be sufficient in number and location to be readily available and accessible within the geographical service area to all enrollees. The HMO must have a sufficient number of primary care physicians and specialists with hospital admitting privileges at participating facilities who are available and accessible 24 hours per day, seven days per week, within the HMO's geographical service area. Additionally, an HMO shall make emergency care available and accessible 24 hours per day, seven days per week, without restrictions as to where the services are rendered.

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Q. What are the accessibility and availability requirements for an HMO?
A.
An HMO is required to provide an adequate network which would consist of contracted physicians and providers for its entire geographical service area.* All covered health care services must be accessible and available to enrollees within certain travel distances. The distance from any point in the HMOs service area to a point of service can be no greater than:

  • 30 miles for primary care and general hospital care; and
  • 75 miles for specialty care, specialty hospitals, and single healthcare service plan physicians or providers.

An HMO must arrange and make available urgent care within:

  • 24 hours for medical and dental conditions; and
  • 24 hours for behavioral health conditions.

An HMO must arrange and make available routine care within:

  • 3 weeks for medical conditions;
  • 8 weeks for non-emergent dental conditions; and
  • 2 weeks for behavioral health conditions

An HMO must arrange and make available preventive care within:

  • 2 months for a child;
  • 3 months for an adult; and
  • 4 months for dental services.

*Geographic Service Area is defined as a geographic area within which direct service benefits are available and accessible to HMO enrollees who live, reside, or work within that geographic area.

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Q. What is an Access plan?
A.
An Access Plan is an action plan filed with the department for approval by the commissioner as received from an HMO. The plan establishes arrangements for healthcare in previously approved or proposed service areas in which the HMO does not have an adequate number of contracted physicians, providers, or facilities. For access plan requirements see 28 TAC §11.1607.

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Utilization Review Agents

Q. Where can I find the most current URA application form?
A.
Please refer to the department's website for the latest application and exhibit checklist at:
http://www.tdi.texas.gov/forms/form9ura.html.

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Q. Does the notary have to be in Texas?
A.
No. The applicant may use any commissioned notary.

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Q. If I delegate utilization review, do I have to be a certified URA?
A.
No, however, the delegate must be certified as a URA.

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Q. I am a URA in another state. What do I need to do to become certified in Texas?
A.
Please see http://www.tdi.texas.gov/hmo/indexura.html which includes information on how to become a certified URA in Texas.

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Q. What is the fee for an original and renewal URA certification?
A.
The fees for an original URA application and renewal are set by rule 28 TAC §19.802(A) and (B). The current fees are $2,150 for an original application and $545 for a renewal.

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Q. Can the application be emailed or faxed?
A.
No, the application and required fee must be mailed to the following address:
Texas Department of Insurance
MCQA Office, Mail Code 103-6A
P O Box 149104
Austin, Texas 78714-9104

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Q. As a certified/registered URA, if my address, contact person, or ownership changes do I need to submit anything to the Department?
A.
 Yes. The URA must fill out and submit the URA Application to notify the department of any material change. The URA application may be obtained at: http://www.tdi.texas.gov/forms/form9ura.html

Pursuant to 28 TAC §19.1704(d) a URA is required to report any material changes in its application or renewal form to the department no later than the 30th day after the date on which the change takes effect. Material changes include, but are not limited to, new officers or directors who are hired to perform utilization review, changes in the URA's organizational structure, changes in the URA's contractual relationships, and changes in the utilization review plan. Pursuant to TIC §4201.106, a certification of registration is not transferable.

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Last updated: 04/17/2015

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