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SUBCHAPTER A. GENERAL PROVISIONS

28 TAC §11.2, SUBCHAPTER Q. OTHER REQUIREMENTS, 28 TAC §11.1607

SUBCHAPTER T. QUALITY OF CARE, 28 TAC §§11.1901-11.1902

The Texas Department of Insurance proposes amendments to §11.2 concerning definitions relating to health maintenance organization (HMO) telehealth services and telemedicine medical services and physician and provider credentialing; §11.1607 concerning accessibility and availability requirements for HMOs providing telemedicine medical services and telehealth services; and §§11.1901-11.1902 concerning quality improvement programs operated by HMOs, including credentialing and recredentialing of physicians and providers. The amendments to §11.2 provide definitions necessary to implement Senate Bill 544 (Acts 2001, 77 th Leg., ch. 1369, §2, eff. Sept. 1, 2001), which enacted Insurance Code Article 20A.39 relating to credentialing of physicians and providers and Senate Bill 789 (Acts 2001, 77 th Leg. ch. 1255, §§5-9, eff. June 15, 2001) which amended the Insurance Code Article 21.53F relating to telemedicine and telehealth services. The amendments to §11.1607 are necessary to clarify the applicability of subsections (i)-(k) to both telehealth services and telemedicine medical services as a result of the enactment of Senate Bill 789. The amendments to §§11.1901 and 11.1902 are necessary to reorganize, clarify, and eliminate redundancy in the current requirements and procedures in these sections, for quality improvement programs operated by HMOs. Section 11.1903, relating to the operation and responsibilities of an HMO quality improvement committee, is proposed for repeal; the proposed repeal is published elsewhere in this issue of the Texas Register. Additionally, the amendments to §11.1902(4) and (5) propose standards necessary to implement Senate Bill 544 which specifies guidelines and standards for rules adopted under the Insurance Code Article 20A.37 that regulate implementation and maintenance of HMO credentialing, the process for selecting and retaining affiliated physicians and providers. Article 20A.37 requires each HM O to have an ongoing internal quality assurance program to monitor and evaluate its health care services in all institutional and noninstitutional contexts and authorizes the Commissioner to establish, by rule, minimum standards and requirements for these programs, including, but not limited to, standards for assuring availability, accessibility, quality and continuity of care.

The proposed amendments to §11.2 clarify that credentialing is the process of collecting, assessing, and validating qualifications and other relevant information pertaining to a physician or provider to determine eligibility to deliver health care services. They also delete the reference to "dentist" in the definition of credentialing and clarify, in the definition of dentist, that a dentist is an individual provider. These changes are consistent with other proposed clarification changes in §§11.1901-11.1902 to include dentists as individual providers in the proposed rules. The proposed amendments also add definitions for individual provider, institutional provider, recredentialing, telehealth service and telemedicine medical services and delete the definition of credentials because it is not necessary.

The proposed amendments to §11.1607(i)-(k) clarify that the current requirements and criteria that apply to an HMO´s provision of telemedicine shall also apply to telehealth services, including that each evidence of coverage delivered or issued for delivery by an HMO may provide enrollees the option to access covered health care services through a telehealth service or a telemedicine medical service. The proposed amendments also change the term "telemedicine" to "telemedicine medical services" for consistency with the Insurance Code Article 21.53F as enacted by Senate Bill 789.

In accordance with Senate Bill 544, amendments to §11.1902(4) and (5) propose standards for credentialing and recredentialing of physicians and providers that are in compliance with the standards in the Insurance Code Article 20A.39 and with standards of the National Committee for Quality Assurance (NCQA), to the extent that the NCQA standards do not conflict with other laws of this state. The NCQA is an independent nonprofit organization that uses performance measures to assess and accredit managed care organizations, including HMOs. The amendments propose standards for credentialing policies and procedures for physicians, individual providers, and institutional providers, including initial and recredentialing primary source verification; the credentialing application; initial and recredentialing sanction information; initial credentialing site visits; performance monitoring; ongoing monitoring of sanctions and complaints; notification to appropriate authorities of actions taken against a physician or provider and physician and provider appeal rights; initial and ongoing assessment of institutional providers; and delegation of credentialing; and uniform requirements and guidelines for HMOs conducting site visits for cause.

Throughout the proposed amendments to §§11.1901-11.1902, two changes are proposed for clarification and simplification with no substantive changes to the current rules: (i) deletion of references to the term "dentists" because the proposed definitions of both of the terms "dentist" and "individual provider," as well as the definition of "provider" in the Insurance Code Article 20A.02(t), result in dentists being included as "individual providers" in the proposed rules; and (ii) specification of "individual providers" and "institutional providers" as appropriate. Also, wherever the current provisions of §11.1903 are incorporated into §§11.1901-11.1902, or current provisions of §§11.1901-11.1902 are reorganized, the current wording is revised in some instances for purposes of clarification and deletion of redundancy and to reflect the Department´s interpretation of current rules.

The proposed amendments to §11.1901 incorporate the various provisions of §§11.1902(8)(B) and 11.1903 relating to the responsibilities of the HMO governing body to receive and review reports on the quality improvement program, including the delegation of quality improvement activities and the use of multidisciplinary teams by the quality improvement committee.

The proposed amendments to §11.1902 clarify that the HMO shall dedicate adequate resources to the quality improvement program, incorporate current §11.1902(2)(C) and clarify that the HMO shall continuously update and monitor the quality improvement program.

The proposed amendments to §11.1902(2) clarify that an annual quality improvement work plan shall include a schedule of activities designed to reflect the population served by the HMO in terms of age groups, disease categories, and special risk status; that an annual quality improvement work plan shall include goals, objectives, and planned projects or activities identified from the previous year, as well as for the current year; time frames for implementation; individuals responsible; and coordination of functions; and what the HMO must include in the annual quality improvement work plan to monitor quality improvement, including objective and measurable quality indicators, process or outcome performance measurements, and data appropriate to the goals and objectives of the activity.

The proposed amendments to §11.1902(2)(C) clarify that the annual quality improvement work plan shall include ongoing or periodic assessment of both quality of care and quality of service in planned projects and specifies what is to be assessed, including network adequacy; continuity of health care and related services; clinical studies; the adoption and annual updating of clinical practice guidelines or clinical care standards; enrollee, physician, and individual provider satisfaction; the complaint and appeal process and complaint data and identification and removal of communication barriers which may impede effective making of complaints against the HMO; preventive health care through promotion and outreach activities; the claims payment processes; contract monitoring, and utilization review processes. Proposed §11.1902(2)(C)(viii) relating to claims payment processes and §11.1902(2)(C)(ix) relating to contract monitoring are included to clarify the general requirement in current §§11.1901-11.1903 regarding a comprehensive quality improvement program and to assess compliance with the Insurance Code Article 20A.18B and 28 TAC §§21.2801-21.2820, which provide guidelines and requirements for the prompt payment of physicians and providers, and the Insurance Code Article 20A.18C related to the delegation of certain functions by HMOs and the monitoring of these delegated functions.

Proposed §11.1902(2)(D) incorporates current §11.1903(G)(i)-(ii) and clarifies that the annual quality improvement work plan shall include ongoing or periodic analysis and evaluation of both quality of clinical care and quality of service in planned projects specified in §11.1902(2)(C).

The proposed amendments to §11.1902(3) incorporate current §11.1903(2)(H)(i)-(ii) and clarify that there shall be an annual written evaluation report on the quality improvement program that includes completed activities, trending of clinical and service indicators, analysis of program performance, conclusions, and demonstrated improvements in care and services.

Most of the proposed amendments to §11.1902(4) are for the purpose of bringing current physician and provider HMO credentialing standards into compliance with the standards in the Insurance Code Article 20A.39 and with NCQA standards, to the extent that the NCQA standards do not conflict with other laws of this state. In compliance with NCQA standards (CR 1.8), proposed §11.1902(4)(A) requires that HMO policies and procedures clearly indicate the physician or provider responsible for the credentialing program. The proposed amendments to §11.1902(4)(B) are for clarification and readability purposes and, consistent with the NCQA standards (CR 1), require written criteria for credentialing of physicians and providers and written procedures for verification. Current §11.1902(5)(A)(ii), relating to annual evaluation of credentialing policies and procedures, is deleted because it is not consistent with NCQA standards.

Current §11.1902(5)(A)(iii) is redesignated as §11.1902(4)(B)(ii) and §11.1902(4)(B)(iii) and amended to clarify who is required and not required to be credentialed. In accordance with NCQA standards (CR 1.1), the only substantive change to the current rule is that pharmacists have been added to those who are not required to be credentialed. Both the current rule and the proposed rule require all dentists to be credentialed, including those who provide dental care only under a dental plan or rider. Insurance Code Articles 20A.03(c) and 20A.37 authorize the Department to regulate dental HMOs, including credentialing of contracted dentists, and the NCQA standards in this instance conflicts with the other laws of this state. Under the Insurance Code Article 20A.39(a), rules adopted by the Commissioner that relate to an HMO´s credentialing of physicians and providers are not required to comply with NCQA standards if those standards conflict with other laws of this state. Both the current rule and the proposed rule require advanced practice nurses (APNs) and physicians´ assistants (PAs) to be credentialed. The NCQA standards do not specifically include or exclude APNs and PAs from credentialing requirements. However, APNs and PAs meet the NCQA definition of practitioners who have an independent relationship with the managed care organization. Additionally, under the Insurance Code Article 20A.02(t), APNs and PAs are considered "providers." The Insurance Code Article 20A.14(j) provides that if an APN or PA is statutorily authorized to provide care by a physician participating in an HMO´s provider network, the HMO may not refuse to contract with an APN or PA to be included in the HMO´s provider network, refuse to reimburse the APN or PA for covered services, or otherwise discriminate against the APN or PA solely because the APN or PA is not identified as a practitioner under the Insurance Code Article 21.52, §3.

Current §11.1902(4)(A)(v) is deleted because the six months verification time limit is incorporated into the proposed rules where appropriate and the two-year site visit verification time limit is not consistent with NCQA standards. Current §11.1902(5)(A)(vii), which requires recredentialing of physicians and individual providers every two years and requires HMOs to maintain documentation of current state licensure, is deleted because the requirements do not comply with NCQA standards or with the Insurance Code Article 20A.39(d). Proposed §11.1902(4)(B)(vi), consistent with NCQA standards (CR 10), specifies procedures for monitoring physician and provider performance between periods of recredentialing.

Current §11.1902(5)(A)(viii) is redesignated as §11.1902(4)(B)(vii) and proposed to be amended to comply with NCQA standards (CR 13) on delegation of credentialing, including required annual audits and exceptions and the requirement that the HMO maintain the right to approve credentialing, suspension, and termination of physicians and providers. The proposed amendments to §11.1902(5)(B)(vii) also clarify that credentialing files maintained by other entities to whom the HMO has delegated credentialing functions be made available to the Department for examination upon request, which is in accordance with the Insurance Code Article 20A.17(b)(4).

Current §11.1902(5)(A)(x) is redesignated as §11.1902(4)(B)(ix) and amended for clarity and compliance with NCQA standards (CR 11) on HMO procedures for notifying appropriate authorities when a physician´s or provider´s affiliation is suspended or terminated due to quality of care concerns.

Current §11.1902(5)(B)(i) is redesignated as §11.1902(4)(C)(i) and amended to require that physicians complete the standardized credentialing application adopted in 28 TAC §21.3201; the proposal for §21.3201 is published elsewhere in this issue of the Texas Register. Proposed amendments to §11.1902(4)(C)(i) also provide that HMOs are not precluded from using the standardized credentialing application form specified in §21.3201 for individual providers and provide, in compliance with NCQA standards (CR 4), that the completion date on the credentialing application shall be within 180 calendar days prior to the date the credentialing committee deems a physician or individual provider eligible for initial credentialing.

Current §11.1902(5)(B)(ii)(I) is redesignated as §11.1902(4)(C)(ii)(I) and amended to provide that, in compliance with NCQA standards (CR 3.1), the license and sanctions must be verified within 180 calendar days prior to the date the credentialing committee deems a physician or individual provider eligible for initial credentialing and the license must be in effect at the time of the credentialing decision.

Current §11.1902(5)B)(ii)(II), relating to requirements for clinical privileges, is deleted because it does not comply with NCQA standards. Current §11.1902(5)(B)(ii)(III), relating to education and training, is redesignated as §11.1902(4)(C)(ii)(II) and amended to provide, consistent with NCQA standards (CR 3.3), that if a specialty board verifies education and training, evidence of board certification shall also serve as a primary source verification of education and training. Current §11.1902(5)(B)(ii)(IV), relating to board certification, is redesignated as §11.1902(4)(C)(ii)(III) and amended to provide, in compliance with NCQA standards (CR 3.4), that the source used must be the most recent available. Current §11.1902(5)(B)(iii)(III), relating to Drug Enforcement Agency and Department of Public Safety Controlled Substances permits, is included in proposed §11.1902(4)(C)(ii)(IV) and amended to comply with NCQA standards (CR 3.2).

In accordance with NCQA standards (CR 3.6), amendments are proposed to §11.1902(4)(C)(iii)(I) to require professional liability claims history to be verified within 180 days prior to the date of the credentialing decision and to be obtained from the professional liability carrier or the National Practitioner Data Bank. In accordance with NCQA standards (CR 5.3), amendments are proposed to §11.1902(4)(C)(iii)(II) to require information on previous sanction activity by Medicare and Medicaid to be verified within 180 days prior to the date of the credentialing decision and to specify seven possible sources, including the National Practitioner Data Bank.

Current §11.1902(5)(B)(iv) is redesignated as §11.1902(4)(C)(iv) and amended, in accordance with NCQA standards (CR 6), to require initial credentialing site visits to each obstetrician-gynecologist and high-volume individual behavioral health provider and to allow one site visit in specified instances of group practice situations. Current §11.1902(5)(B)(v) is redesignated as §11.1902(4)(C)(v) and amended, in accordance with the Insurance Code Article 20A.39(c), to require that site visit evaluations consist of appointment availability. Proposed amendments to §11.1902(4)(C)(v) also provide that if a physician or individual provider offers services such as radiology or laboratory services that require certification or licensure in accordance with the Insurance Code Article 20A.39(b), the current certification or licensure must be available for review at the initial credentialing site visit. In accordance with NCQA standards (CR 6), proposed amendments to §11.1902(4)(C)(v) require corrective action plans and follow-up site visits every six months until the site meets the HMO´s standards.

Current §11.1902(5)(C) is redesignated as §11.1902(4)(D) and amended, in accordance with the Insurance Code Article 20A.39(d)(1), to require HMOs to recredential physicians and individual providers at least once every three years. Proposed amendments to §11.1902(4)(D), in accordance with NCQA standards (CR 9), require HMOs to consider performance indicators for primary care and high-volume individual behavioral health care providers in recredentialing decision making. Proposed amendments to §11.1902(5)(D)(i)-(ii), in accordance with NCQA standards (CR 7), require reverification from specified primary sources and in accordance with the verification time limit for the initial credentialing process in proposed §11.1902(4)(C), and delete the current §11.1902(5)(C)(iii) requirements for recredentialing site visits for primary care physicians and high-volume physicians and providers and multi-practitioners every two years.

Current §11.1902(5)(D) is redesignated as §11.1902(4)(E) and amended in §11.1902(4)(E)(i)-(v), in accordance with NCQA standards (CR 12), to specify the credentialing process for institutional providers, including on-site evaluation of the institutional provider against the HMO´s written standards if the provider is not accredited by the HMO-required national accrediting body. Recredentialing of institutional providers at least every three years, is addressed in proposed §11.1902(4)(F). Proposed §11.1902(4)(F) also provides, in accordance with NCQA standards (CR 12.5), that the recredentialing process shall update information obtained for initial credentialing.

Proposed §11.1902(4)(G), in accordance with the Insurance Code Article 20A.39(a), provides that if the NCQA standards change and there is a difference between the Department´s promulgated standards and the NCQA standards, that the NCQA standards shall prevail to the extent those standards do not conflict with the other laws of this state.

Proposed §11.1902(5)(A), in accordance with NCQA standards (CR 6.7), requires the HMO to have procedures for detecting deficiencies subsequent to the initial site visit and to reevaluate the site and institute actions for improvement when the HMO identifies new deficiencies. Proposed §11.1902(5)(B), in accordance with the Insurance Code Article 20A.39(e), specifies the requirements and guidelines for HMOs conducting site visits for cause.

These amendments are proposed to be effective July 1, 2002, with the standardized credentialing application form for physicians required in §11.1902(4)(C)(i) to be used for initial credentialing or recredentialing that occurs on or after July 1, 2002.

Kimberly Stokes, Senior Associate Commissioner, Life/Health/Licensing, has determined that during the first five years the proposed amendments will be in effect, there will be no fiscal impact on state or local government as a result of enforcing or administering the proposed amendments. There will be no measurable effect on local employment or the local economy as a result of administering or enforcing the proposed amendments.

Ms. Stokes has determined that for each year of the first five years the amendments are in effect, the public benefits anticipated as a result of the adoption of the amendments to §11.1607(i)-(k) are updated rules consistent with the Insurance Code Article 21.53F as amended by Senate Bill 789, clarification of the information to be provided to the enrollee on the evidence of coverage regarding the enrollee´s ability to access covered telehealth services and telemedicine medical services, and promotion of awareness of the telemedicine medical services and telehealth services coverage that may be provided by the HMO. The public benefits anticipated as a result of the adoption of the proposed amendments to §11.1901 and §11.1902 are clarified and better organized operational procedures and standards for HMO governing bodies and quality improvement programs, which are easier to understand and follow. These amendments can also assist HMOs in earlier identification of potential problem areas, such as network adequacy, continuity of care, and claims payments, thereby enabling the HMO to address such problems before they become major and adversely affect the care provided to enrollees. The additional public benefits anticipated as a result of the adoption of the amendments to §11.1902(4) and (5)(A) are Department standards for credentialing of physicians and providers that are consistent with NCQA standards. This will result in greater efficiency and lower administrative costs for those HMOs that are NCQA accredited because they will be required to comply with only one set of credentialing standards. This will also result in lower administrative costs for all HMOs because credentialing of physicians and individual providers will be required every three years, instead of every two years as required under the current rules, and because site visits for primary care physicians and high-volume physicians and providers will no longer be required at recredentialing. These lower administrative costs may also help keep premium costs down because costs to operate the HMOs are used in determining the premium charged to enrollees. In addition, while the proposed rules require HMOs to have a method of verifying licensure and sanctions during the three years between recredentialing, the HMOs will no longer be required to verify licensure prior to or on the expiration date of the license. As a result, each HMO will be able to design a credentialing process that best fits its organizational and economic needs. Also, the three-year recredentialing cycle for physicians and individual providers and the required use of the standardized credentialing application for physicians and the permissive use of this application for individual providers will result in a more efficient and less time-consuming credentialing process. The public benefits anticipated as a result of the adoption of proposed §11.1902(5)(B) are updated rules consistent with the Insurance Code Article 20A.39(e); specification of uniform requirements and guidelines for HMOs conducting site visits for cause; and earlier identification and correction of quality of care problems, including those related to patient safety, accessibility, and appointment availability.

Any economic costs required to comply with the proposed amendments to §11.1607(i)-(k), are the direct result of the legislative enactment of Senate Bill 789. Any economic costs required to comply with the proposed amendments to §11.1902(4) and §11.1902(5) are the direct result of the legislative enactment of Senate Bill 544, and the directive in the Insurance Code Article 20A.39(a) that the rules adopted by the Commissioner under the Insurance Code Article 20A.37 that relate to an HMO´s process for selecting and retaining affiliated physicians and providers comply with NCQA standards, to the extent those standards do not conflict with other laws of this state, and with the standards enacted in the Insurance Code Article 20A.39. There are no additional costs anticipated to persons or entities who are required to comply with the proposed amendments to §11.2 and to §§11.1901-11.1902(1)-(3) and (6) that reorganize, clarify, and delete redundancy in current §§11.1901-11.1903.

Ms. Stokes has determined that there is no adverse economic effect on any HMO that qualifies as a small business or micro-business under the Government Code §2006.001, as a result of the proposed amendments. All of the economic costs to any small business or micro-business HMO required to comply with the proposed amendments to §11.1607(i)-(k) are the direct result of the legislative enactment of Senate Bill 789; in addition, the provision of covered health care services through a telehealth service or a telemedicine medical service is at the option of the HMO and such costs are included in the premium costs paid by the enrollees. The determining factors in the costs that would be incurred by an HMO in complying with the proposed amendments to §11.1607(i)-(k) are whether the HMO opts to provide the telehealth or telemedicine medical services and are not related to the size of the HMO. All of the economic costs to any small business or micro-business HMO required to comply with the proposed amendments to §11.1902(4) and (5)(A) are the direct result of the legislative enactment of Senate Bill 544, and its directive that the rules adopted by the Commissioner under the Insurance Code Article 20A.37 that relate to an HMO´s process for selecting and retaining affiliated physicians and providers comply with NCQA standards, to the extent those standards do not conflict with other laws of this state, and with the standards enacted in the Insurance Code Article 20A.39. The determining factors in the costs that would be incurred by an HMO in complying with the proposed amendments to §11.1902(4) and (5)(A) are not related to the size of the entity, but rather to the implementation and maintenance of the HMO´s quality improvement program, including the credentialing and recredentialing of physicians and providers, which all HMOs, regardless of size, are required by the Insurance Code Article 20A.37 to implement and maintain. All of the economic costs required to comply with proposed & sect;11.1902(5)(B) are the direct result of the legislative enactment of Insurance Code Article 20A.39(e) in Senate Bill 544. The determining factors in the costs that would be incurred by an HMO in complying with the proposed amendments to §11.1902(5)(B) are not related to the size of the HMO, but rather to the number of physician and provider offices for which site visits for cause are required. Therefore, the size of the HMO has no bearing upon the applicability of any of the proposed amendments. Because of this; the intent of Senate Bill 544 to bring Texas standards for credentialing physicians and providers into compliance with the NCQA standards; the intent of the Insurance Code Article 20A.39(e) that all HMOs, regardless of size, not be precluded from conducting a site visit to the office of any physician or provider at any time for cause; and the intent of the Insurance Code Article 20A.37 that all HMOs, regardless of size, implement and maintain a quality assurance program, it is neither legal nor feasible to exempt small business or micro-business HMOs from the requirements of the proposed amendments. Additionally, because the provision of telehealth services and telemedicine medical services is at the option of the HMO, it is not necessary to exempt small business or micro-business HMOs from the requirements of the proposed amendments to §11.1607(i)-(k).

To be considered, written comments on the proposal must be submitted no later than 5:00 p.m. on May 28, 2002 to Lynda H. Nesenholtz, General Counsel and Chief Clerk, Mail Code 113-1C, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. An additional copy of the comment must be simultaneously submitted to Margaret Lazaretti, Director of Project Development, Life/Health/Licensing, Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. A request for a public hearing must be submitted separately to the Office of Chief Clerk.

The amendments are proposed pursuant to the Insurance Code Articles 20A.39, 20A.37, 21.58D, and §36.001. Article 20A.39(a) requires the rules adopted under Article 20A.37 that relate to implementation and maintenance by an HMO of a process for selecting and retaining affiliated physicians and providers to comply with the provisions of new Article 20A.39 and the standards promulgated by the National Committee for Quality Assurance, to the extent that those standards do not conflict with other laws of this state. Article 20A.37(b) requires each HMO to have an ongoing internal quality assurance program to monitor and evaluate its health care services in all institutional and noninstitutional contexts and authorizes the Commissioner to establish, by rule, minimum standards and requirements for these programs, including, but not limited to, standards for assuring availability, accessibility, quality and continuity of care. Article 21.58D requires the Commissioner by rule to adopt a standardized form for the verification of the credentials of a physician and to require HMOs operating under the Insurance Code Chapter 20A to use the form. Section 36.001 provides that the Commissioner of Insurance may adopt rules to execute the duties and functions of the Texas Department of Insurance only as authorized by statute.

The following articles are affected by the proposal: Insurance Code Articles 21.53F, 20A.39, 20A.37, 21.58D

§11.2. Definitions.

(a) (No change.)

(b) The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise.

(1) ­ (13) (No change.)

(14) Credentialing--The process of collecting, assessing, and validating [ review of] qualifications and other relevant information pertaining to a physician[ , dentist,] or provider to determine eligibility to deliver health care services [ who seeks a contract with an HMO].

(15) [ Credentials--Certificates, diplomas, licenses or other written documentation which verifies proof of training, education, and experience in a field of expertise.]

[ (16)] Dentist--An individual provider licensed to practice dentistry by the Texas State Board of Dental Examiners. (16)[ (17)] General hospital--A licensed establishment that:

(A) offers services, facilities, and beds for use for more than 24 hours for two or more unrelated individuals requiring diagnosis, treatment, or care for illness, injury, deformity, abnormality, or pregnancy; and

(B) regularly maintains, at a minimum, clinical laboratory services, diagnostic X-ray services, treatment facilities including surgery or obstetrical care or both, and other definitive medical or surgical treatment of similar extent.

(17)

[ (18)] HMO--A health maintenance organization as defined in Insurance Code Article 20A.02(n). (18)[ (19)] Health status related factor--Any of the following in relation to an individual:

(A) health status;

(B) medical condition (including both physical and mental illnesses);

(C) claims experience;

(D) receipt of health care;

(E) medical history;

(F) genetic information;

(G) evidence of insurability (including conditions arising out of acts of domestic violence, including family violence as defined by the Insurance Code Article 21.21-5); or

(H) disability.

(19) Individual provider--Any person, other than a physician or institutional provider, who is licensed or otherwise authorized to provide a health care service. Includes, but is not limited to, licensed doctor of chiropractic, dentist, registered nurse, advanced practice nurse, physician assistant, pharmacist, optometrist, registered optician, and acupuncturist.

(20) Institutional provider--A provider that is not an individual. Includes any medical or health related service facility caring for the sick or injured or providing care or supplies for other coverage which may be provided by the HMO. Includes but is not limited to:

(A) General hospitals,

(B) Psychiatric hospitals,

(C) Special hospitals,

(D) Nursing homes,

(E) Skilled nursing facilities,

(F) Home health agencies,

(G) Rehabilitation facilities,

(H) Dialysis centers,

(I) Free-standing surgical centers,

(J) Diagnostic imaging centers,

(K) Laboratories,

(L) Hospice facilities,

(M) Infusion services centers,

(N) Residential treatment centers,

(O) Community mental health centers,

(P) Urgent care centers, and

(Q) Pharmacies.

(21)[ (20)] Limited provider network--A subnetwork within an HMO delivery network in which contractual relationships exist between physicians, certain providers, independent physician associations and/or physician groups which limit the enrollees´ access to only the physicians and providers in the subnetwork.

(22)[ (21)] Limited service HMO--An HMO which has been issued a certificate of authority to issue a limited service health care plan as defined in the Insurance Code Article 20A.02(l).

(23)[ (22)] Out of area benefits--Benefits that the HMO covers when its enrollees are outside the geographical limits of the HMO service area.

(24)[ (23)] Pathology services--Services provided by a licensed laboratory which has the capability of evaluating tissue specimens for diagnoses in histopathology, oral pathology, or cytology.

(25)[ (24)] Pharmaceutical services--Services, including dispensing prescription drugs, as defined in the Pharmacy Act, Texas Civil Statutes, Article 4542a-1, §5 that are ordinarily and customarily rendered by a pharmacy or pharmacist.

(26)

[ (25)] Pharmacist--An individual provider licensed to practice pharmacy under the Pharmacy Act, Texas Civil Statutes, Article 4542a-1.

(27)[ (26)] Pharmacy--A facility licensed under the Pharmacy Act, Texas Civil Statutes, Article 4542a-1 §29.

(28)[ (27)] Premium--The prospectively determined rate that is paid by or on behalf of an enrollee for specified health services.

(29)[ (28)] Primary care physician or primary care provider--A physician or individual provider who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referral for care.

(30)[ (29)] Primary HMO--An HMO that contracts directly with, and issues an evidence of coverage to, individuals or organizations to arrange for or provide a basic, limited, or single health care service plan to enrollees on a prepaid basis.

(31)[ (30)] Provider HMO--An HMO that contracts directly with a primary HMO to provide or arrange to provide health care services on behalf of the primary HMO within the primary HMO´s defined service area.

(32)[ (31)] Psychiatric hospital--A licensed hospital which offers inpatient services, including treatment, facilities and beds for use beyond 24 hours, for the primary purpose of providing psychiatric assessment and diagnostic services and psychiatric inpatient care and treatment for mental illness. Such services must be more intensive than room, board, personal services, and general medical and nursing care. Although substance abuse services may be offered, a majority of beds must be dedicated to the treatment of mental illness in adults and/or children.

(33)[ (32)] Qualified HMO--An HMO which has been federally approved under Title XIII of the Public Health Service Act, Public Law 93-222, as amended.

(34)[ (33)] Quality improvement--A system to continuously examine, monitor and revise processes and systems that support and improve administrative and clinical functions.

(35) Recredentialing--The periodic process by which:

(A) qualifications of physicians and providers are reassessed;

(B) performance indicators, including utilization and quality indicators, are evaluated; and

(C) continued eligibility to provide services is determined.

(36)[ (34)] Reference laboratory--A licensed laboratory that accepts specimens for testing from outside sources and depends on referrals from other laboratories or entities. HMOs may contract with a reference laboratory to provide clinical diagnostic services to their enrollees.

(37)[ (35)] Reference laboratory specimen procurement services--The operation utilized by the reference laboratory to pick up the lab specimens from the client offices or referring labs, etc. for delivery to the reference laboratory for testing and reporting.

(38)[ (36)] Referral specialists (other than primary care)--Physicians or individual providers who set themselves apart from the primary care physician or primary care provider through specialized training and education in a health care discipline.

(39)

[ (37)] Schedule of charges--Specific rates or premiums to be charged for enrollee and dependent coverages.

(40)[ (38)] Service area--A geographic area within which direct service benefits are available and accessible to HMO enrollees who live, reside or work within that geographic area and which complies with §11.1606 of this title (relating to Organization of an HMO).

(41)[ (39)] Single service HMO--An HMO which has been issued a certificate of authority to issue a single health care service plan as defined in the Insurance Code Article 20A.02(y).

(42)[ (40)] Special hospital--A licensed establishment that:

(A) offers services, facilities and beds for use for more than 24 hours for two or more unrelated individuals who are regularly admitted, treated and discharged and who require services more intensive than room, board, personal services, and general nursing care;

(B) has clinical laboratory facilities, diagnostic X-ray facilities, treatment facilities or other definitive medical treatment;

(C) has a medical staff in regular attendance; and

(D) maintains records of the clinical work performed for each patient.

(43)

[ (41)] Statutory surplus--Admitted assets minus accrued uncovered liabilities.

(44)[ (42)] Subscriber--If conversion or individual coverage, the individual who is the contract holder and is responsible for payment of premiums to the HMO; or if group coverage, the individual who is the certificate holder and whose employment or other membership status, except for family dependency, is the basis for eligibility for enrollment in the HMO.

(45)

[ (43)] Subsidiary--An affiliate controlled by a specified person directly or indirectly through one or more intermediaries.

(46) Telehealth service--As defined in Section 57.042, Utilities Code.

(47)[ (44)] Telemedicine medical service--As defined in Section 57.042, Utilities Code [ the Insurance Code Article 21.53F].

(48)

[ (45)] Urgent care--Health care services provided in a situation other than an emergency which are typically provided in a setting such as a physician or individual provider´s office or urgent care center, as a result of an acute injury or illness that is severe or painful enough to lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, illness, or injury is of such a nature that failure to obtain treatment within a reasonable period of time would result in serious deterioration of the condition of [ or] his or her health.

(49)[ (46)] Utilization review--A system for prospective or concurrent review of the medical necessity and appropriateness of health care services being provided or proposed to be provided to an individual within this state. Utilization review shall not include elective requests for clarification of coverage.

(50)[ (47)] Voting security--As defined in the Insurance Code Article 21.49-1, including any security convertible into or evidencing a right to acquire such security.

(51)[ (48)] NAIC--National Association of Insurance Commissioners.

(52)[ (49)] Annual financial statement--The annual statement to be used by HMOs, as promulgated by the NAIC and as adopted by the commissioner under Insurance Code Articles 1.11 and 20A.10.

(53)[ (50)] RBC--Risk-based capital.

(54)[ (51)] RBC formula--NAIC risk-based capital formula.

(55)[ (52)] Authorized control level--The number determined under the RBC formula in accordance with the RBC instructions.

(56)[ (53)] RBC Report--1999 NAIC Managed Care Organizations Risk-Based Capital Report including Overview and Instructions for Companies published by the NAIC.

(57)[ (54)] Total adjusted capital--An HMO's statutory capital and surplus/total net worth as determined in accordance with the statutory accounting applicable to the annual financial statements required to be filed pursuant to the Insurance Code, and such other items, if any, as the RBC instructions provide.

§11.1607. Accessibility and Availability Requirements.

(a)-(h) (No change.)

(i) Each evidence of coverage or certificate delivered or issued for delivery by an HMO may provide enrollees the option to access covered health care services through a telehealth service or a telemedicine medical service.

(j) Before providing telehealth services or telemedicine medical services to an enrollee, an HMO shall provide the enrollee with the option to select a physician or provider within the HMO delivery network to provide the covered health care services, or to elect to receive telehealth services or telemedicine medical services.

(k) In order to provide covered health care services to any enrollee by a telehealth service or a telemedicine medical service, an HMO shall satisfy the criteria specified under subsection (a) of this section.

§11.1901. Quality Improvement Structure.

(a) The HMO shall develop and maintain an ongoing quality improvement program designed to objectively and systematically monitor and evaluate the quality and appropriateness of care and services [ service provided to enrollees ] and to pursue opportunities for improvement.

(b) The HMO governing body is ultimately responsible for the overall quality improvement program. The HMO governing body shall:

(1) appoint a [the formal] quality improvement committee that [which] shall include practicing physicians, [ dentists,] individual [ other] providers and at least one enrollee from throughout the HMO's service area. For purposes of this section, the enrollee appointed to the committee may not be an employee of the HMO;

(2) approve the quality improvement program;

(3) approve an annual quality improvement plan; [ and]

(4) meet no less than annually to receive and review reports of the quality improvement committee or group of committees and take action when appropriate ; and [ .]

(5) review the annual written report on the quality improvement program.

(c) The quality improvement committee shall develop and evaluate the overall effectiveness of the quality improvement program.

(1) The quality improvement committee may delegate quality improvement activities to other committees that may, if applicable, include practicing physicians, individual providers, and enrollees from throughout the service area.

(A) All committees shall collaborate and coordinate efforts to improve the quality, availability, and accessibility of health care services to be furnished by the HMO to its enrollees.

(B) All committees shall meet and regularly report findings, recommendations, and resolutions in writing through the quality improvement committee to the HMO governing body.

(C) If the quality improvement committee delegates any quality improvement activity to any subcommittee, then the quality improvement committee must establish a method of oversight of each subcommittee.

(2) The quality improvement committee shall use multidisciplinary teams, when indicated, to accomplish quality improvement program goals.

§11.1902. Quality Improvement Program. The quality improvement program shall be continuous and comprehensive , including both the quality of clinical care and the quality of service [ requiring updates as needed]. The HMO shall dedicate adequate resources such as personnel, analytic capabilities, and data resources to the quality improvement program [ that are adequate to meet the needs of the program]. The HMO shall continuously update and monitor the quality improvement program.

(1) Written description. There shall be a written description of the quality improvement program that outlines program organizational structure, functional responsibility and design.

(2) Work plan. There shall be an annual quality improvement work plan[ , or schedule of activities,] that includes a schedule of activities designed to reflect the population served by the HMO in terms of age groups, disease categories, and special risk status. The work plan shall include but [ is] not be limited to the following:

(A) Goals, objectives, [ scope,] and planned projects or activities identified from the previous year, as well as for the current year ; time frames for implementation; responsible individuals; and coordination of functions.[ ;]

(B)Use of quality indicators, performance measurements, and quality improvement data collection to monitor quality improvement.

(i) Quality indicators must be objective, measurable, and include performance goals for each indicator.

(ii) Performance measures must be process or outcome measures.

(iii) Data collected must be appropriate to the goals and objectives of the activity. [ planned monitoring of previously identified issues, including tracking of issues over time; and]

(C) Ongoing or periodic assessment of both quality of clinical care and quality of service in planned projects, specifically: [ planned evaluation and modification, if necessary, of the quality improvement program.]

(i) Network adequacy, which includes availability and accessibility of care, including assessment of open/closed physician and individual provider panels;

(ii) Continuity of health care and related services;

(iii) Clinical studies, which shall specify methodologies to be used to accomplish them;

(iv) The adoption and annual updating of clinical practice guidelines or clinical care standards, compatible with current principles of health care; the quality improvement program shall assure the practice guidelines:

(I) are approved by participating physicians and individual providers;

(II) are included in physician and provider manuals; and

(III) include preventive health services.

(v) Enrollee, physician, and individual provider satisfaction;

(vi) The complaint and appeal process, complaint data, and identification and removal of communication barriers which may impede enrollees, physicians, and providers from effectively making complaints against the HMO;

(vii) Preventive health care through health promotion and outreach activities:

(I) The HMO shall inform and educate physicians and providers about using the health management and outreach programs for the enrollees assigned to them.

(II) Outreach may be accomplished through, but not limited to, written educational materials, community-based programs and presentations, health promotion fairs, and monetary contributions to community-based organizations and health related initiatives of other programs.

(viii) Claims payment processes;

(ix) Contract monitoring, including delegation oversight and compliance with filing requirements; and

(x) Utilization review processes.

(D) Ongoing or periodic analysis and evaluation of both quality of clinical care and quality of service planned projects specified in subparagraph (C) of this paragraph, which shall include:

(i) Evidence that results of evaluation are used to improve clinical care and services; and

(ii) A systematic method of tracking areas identified for improvement to assure that appropriate action is taken to effect the needed improvement.

(3) Evaluation [ Monitoring and evaluation]. There shall be an annual written report on the quality improvement program, which includes completed activities, trending of clinical and service indicators, analysis of program performance, conclusions, and demonstrated improvements in care and services. [The program monitoring and evaluation of clinical issues shall reflect the population served by the HMO in terms of age groups, disease categories, and special risk status. Monitoring and evaluation of clinical issues shall include:]

[ (A) care and services provided in institutional settings;]

[ (B) care and services provided in noninstitutional settings, including, but not limited, to practitioner offices and home and community support services agencies; and]

[ (C) primary care and major specialty services, including but not limited to mental health, cancer, burn or cardiac centers.]

(4) [ Identifying special needs. The quality improvement program shall identify enrollees with special needs such as disabilities and chronic conditions in order to assist the HMO in facilitating the development and implementation of appropriate courses of care to assure that health care services are available and accessible.]

[ (5)] Credentialing. An HMO shall implement a documented process for selection and retention of contracted physicians and [ affiliated] providers, which includes the following elements, as applicable:

(A) The HMO´s policies and procedures shall clearly indicate the physician or individual provider directly responsible for the credentialing program and shall include a description of his or her participation.

(B) HMOs shall develop written criteria for credentialing of physicians and providers and [ appropriate to the nature of the services to be furnished to enrollees. HMOs shall also develop] written procedures for verifications.

(i) [The governing body shall approve the policies and procedures.]

[(ii) The policies and procedures shall be evaluated by practicing physicians and providers on at least an annual basis.] [ (iii)] Credentialing is [ shall be] required for all physicians and [ other] providers, including [ who are permitted to practice independently under state law. Except for] advanced practice nurses , [ and] physicians´ assistants , and physicians and individual providers who are hospital-based and listed in the provider directory. Physicians or providers who are members of a contracting group, such as an independent physician association or medical group, shall be credentialed individually.

Credentialing [ credentialing] is not required for:

(I) individual providers who furnish services only under the direct supervision of a physician or another individual provider except as specified in clause (i) of this subparagraph;

(II) hospital-based physicians or individual providers [ who provide services incident to hospital services], except as specified in clause (i) of this subparagraph;[ unless those physicians or providers are separately identified in enrollee materials as available to enrollees.]

(III) students [ Students], residents, or fellows ; or [ do not require credentialing. Physicians or providers who are members of a contracting group shall be credentialed individually.]

(IV) pharmacists.

(iii) [ (iv)] The initial credentialing process, including application, verification of information, and a site visit (if applicable), must be completed before the effective date of the initial contract with the physician or provider.

[ (v) Information collected pursuant to subparagraphs (B)(ii) and (iii) of this paragraph must be no more than six months old on the date on which the physician, dentist, or provider is determined to be eligible for contract by a peer review or credentialing committee , with the exception of information relating to the site visit and medical record review, which shall be no more than two years old.]

(iv)[ (vi)] An HMO shall have written policies and procedures for suspending or terminating affiliation with a contracting physician or provider, including an appeals process, pursuant to the Insurance Code Article 20A.18A(b).

(v)[ (vii)] The HMO shall have a procedure for the ongoing monitoring of physician and provider performance between periods of recredentialing and shall take appropriate action when occurrences of poor quality are identified. Monitoring shall include, but not be limited to:

(I) Medicare and Medicaid sanctions;

(II) Information from state licensing boards regarding sanctions or licensure limitations; and

(III) Complaints. [ The HMO shall have written procedures for recredentialing at least every two years through a process that updates information obtained in initial credentialing and considers performance indicators. The HMO shall maintain documentation of current state licensure and required permits to practice.]

(vi)[ (viii)] If the HMO delegates [ the] credentialing functions to other entities, it shall have a process for developing [ written procedures for] delegation criteria and for performing [ of credentialing functions to other entities which include, but are not limited to, criteria for delegation,] pre-delegation and annual audits [ audit procedure and criteria], a delegation agreement, a monitoring plan, and a procedure for termination of the delegation agreement for non-performance. If the HMO delegates credentialing functions to an entity accredited by the National Committee for Quality Assurance, the annual audit of that entity is not required ; however, evidence of this accreditation shall be made available to the department for review. The HMO shall maintain documentation of [ Documentation of] pre-delegation and annual audits [ evaluations performed], executed delegation agreements, reports received from the delegated entities, current rosters or copies of signed contracts with [ of] physicians and providers who are affected by the delegation agreement, and ongoing [ continuing] monitoring and shall make this documentation [ evaluations shall be maintained by the HMO and made] available to the department for review. Credentialing files maintained by [ at] the other entities to whom the HMO has delegated credentialing functions [ delegated entity] shall be made available to the department for examination upon request. In all cases, the HMO shall maintain the right to approve credentialing, suspension, and termination of physicians and providers.

(vii)[ (ix)] The HMO´s procedures shall ensure that selection and retention criteria do not discriminate against physicians or providers who serve high-risk populations or who specialize in the treatment of costly conditions.

(viii)[ (x)] The HMO [ HMO´s procedures] shall have [ include] a procedure for notifying licensing [ or disciplinary bodies] or other appropriate authorities when a physician´s [ practitioner´s] or provider´s affiliation s suspended or terminated due to quality of care concerns [ deficiencies].

(C)[ (B)] Initial credentialing process for physicians and individual providers shall include, but not be limited to, the following:

(i) Physicians [ The applicant] shall complete the standardized credentialing [ an] application [ for affiliation. The application] adopted in §21.3201 of this title (relating to the Texas Standardized Credentialing Application for Physicians) and individual providers shall complete an application which includes [ shall include] a work history covering at least five years , [ and] a statement by the applicant regarding any limitations in ability to perform the functions of the position, history of loss of license and/or felony convictions; and history of loss or limitation of privileges , sanctions or other disciplinary activity , current professional liability insurance coverage information, and information on whether the individual provider will accept new patients from the HMO. This does not preclude an HMO from using the standardized credentialing application form specified in §21.3201 of this title for credentialing of individual providers. The completion date on the application shall be within 180 calendar days prior to the date the credentialing committee deems a physician or individual provider eligible for initial credentialing [ The application shall also include whether the physician will accept new patients from the HMO].

(ii) The following shall be verified from primary sources and evidence of verification shall be included in the credentialing files:

(I) A current [ valid] license to practice in the State of Texas and information on sanctions or limitations on licensure. The primary source for verification shall be the state licensing agency or board for Texas , and the license and sanctions must be verified within 180 calendar days prior to the date the credentialing committee deems a physician or individual provider eligible for initial credentialing. The license must be in effect at the time of the credentialing decision.

(II) [ If applicable, clinical privileges in good standing at the hospital designated by the physician or dentist as the primary network admitting facility. The primary source for verification shall be the hospital.]

[ (III)] Education and training, including evidence of graduation from the appropriate professional school and completion of a residency or specialty training, if applicable. Primary source verification shall be sought from the appropriate schools and[ ,] training facilities or the American Medical Association´s MasterFile. If the state licensing board , [ or] agency , or specialty board verifies education and training with the physician´s [ physician] or individual provider´s schools and facilities, evidence of current state licensure or board certification shall also serve as primary source verification of education and training.

(III)[ (IV)] Board certification, if the physician or individual provider indicates [ states] that he/she is board certified on the application. Primary source verification may be obtained from the American Board of Medical Specialties Compendium, the American Osteopathic Association, the American Medical Association MasterFile, or from the specialty boards, and the source used must be the most recent available.

(IV) Valid Drug Enforcement Agency (DEA) or Department of Public Safety (DPS) Controlled Substances Registration Certificate, if applicable. These must be in effect at the time of the credentialing decision and may be verified by any one of the following means:

(-a-) copy of the DEA or DPS certificate;

(-b-) visual inspection of the original certificate;

(-c-) confirmation with DEA or DPS;

(-d-) entry in the National Technical Information Service database; or

(-e-) entry in the American Medical Association Physician Master File.

(iii) The following shall be verified within 180 calendar days prior to the date of the credentialing decision and shall also be included in the physician´s [ physician] or individual provider´s credentialing file:

(I) Past five years of [ Malpractice] history of professional liability claims that resulted in settlements or judgments paid by or on behalf of the physician or individual provider, which may be obtained from the professional liability carrier or the National Practitioner Data Bank;

(II) Information on previous sanction activity by Medicare and Medicaid[ ;] which may be obtained from one of the following:

(-a-) National Practitioner Data Bank;

(-b-) Cumulative Sanctions Report available over the internet;

(-c-) Medicare and Medicaid Sanctions and Reinstatement Report distributed to federally contracting HMOs;

(-d-) state Medicaid agency or intermediary and the Medicare intermediary;

(-e-) Federation of State Medical Boards;

(-f-) Federal Employees Health Benefits Program department record published by the Office of Personnel Management, Office of the Inspector General;

(-g-) entry in the American Medical Association Physician Master File.

[ (III) Copy of a valid Drug Enforcement Agency (DEA) and Department of Public Safety Controlled Substance permit, if applicable;]

[ (IV) Evidence of current, adequate malpractice insurance meeting the HMO´s requirements;]

[ (V) Information about sanctions or limitations on licensure from the applicable state licensing agency or board].

(iv) The HMO shall perform a site visit to the offices of each primary care physician, obstetrician-gynecologist, [ or] primary care dentist, and high-volume individual behavioral health provider as part of the initial credentialing process. In addition, the HMO shall have written procedures for determining [ the] high-volume [ physicians and] individual behavioral health [ non-institutional] providers. If physicians or individual providers are part of a group practice which shares the same office, one visit to the site may be used for all physicians or individual providers in the group practice, as well as for new physicians or individual providers who subsequently join the group practice. The site visit assessment shall be made available to the department for review [ all physicians and providers in that office as long as medical records for each physician or provider are sampled].

(v) Site visits shall [be conducted by clinical personnel (or teams including clinical personnel), and shall] consist of an evaluation of the site´s accessibility, appearance, appointment availability, and space, [ and of the adequacy of equipment,] using standards approved [ developed] by the HMO. If a physician or individual provider offers services that require certification or licensure, such as laboratory or radiology services, the physician or individual provider shall have the current certification or licensure available for review at the site visit. In addition, as a result of the site visits, it shall be determined whether the site conforms to the HMO´s standards for [ medical or dental] record organization, documentation, [keeping practices] and confidentiality practices [ requirements]. Should the site not conform to the HMO´s standards, the HMO shall require a corrective action plan and perform a follow-up site visit every six months until the site complies with the standards.

(D)[ (C)] The HMO shall have written procedures for recredentialing physicians and individual providers at least every three years through a process that updates information obtained in initial credentialing, including professional liability coverage. The process shall also consider performance indicators for primary care and high-volume individual behavioral health care providers, including enrollee complaints and information from quality improvement activities. Recredentialing procedures [ for physicians and individual providers] shall include, but not be limited to, the following processes:

(i) Reverification of the following [ The following shall be reverified] from the primary sources and in accordance with the same verification time limit as for the initial credentialing process specified in subparagraph (C) of this paragraph:

(I) Licensure and information on sanctions or limitations on licensure;

(II) [ Clinical privileges;]

[ (III)] Board certification : [ only]

(-a-) if the physician or individual provider [ dentist] was due to be recertified; or

(-b-) if the physician or individual provider indicates [ states] that he or she has become board certified since the last time he or she was credentialed or recredentialed ; and

(III) Drug Enforcement Agency (DEA) or Department of Public Safety (DPS) Controlled Substances Registration Certificate, if applicable. These may be reverified by any one of the following means:

(-a-) copy of the DEA or DPS certificate;

(-b-) visual inspection of the original certificate;

(-c-) confirmation with DEA or DPS;

(-d-) entry in the National Technical Information Service database; or

(-e-) entry in the American Medical Association Physician Master File.

(ii) Updated history of professional liability claims, and [ The HMO shall requery the National Practitioner Data Bank to and obtain updated] sanction and [ or] restriction information from [ licensing agencies,] Medicare[ ,] and Medicaid in accordance with the verification sources and time limits specified in subparagraph (C)(iii) of this paragraph.

[ (iii) Site visits conducted by clinical personnel (or teams including clinical personnel) shall be repeated for primary care physicians and high-volume physicians and providers. Multi-practitioner sites should be visited every two years. Medical record audits, including evaluation of the quality of encounter notes, shall be performed within the two years prior to recredentialing.]

(E)[ (D)] The credentialing [ Credentialing] process for institutional providers shall include[ , but not be limited to,] the following:

(i) Evidence [ The HMO procedure shall require evidence] of state licensure ;[ , and of compliance with any other applicable state or federal requirements.]

(ii) Evidence [ The HMO procedure may require evidence] of Medicare certification ; [ , as applicable, or accreditation by the Joint Commission on Accreditation of Healthcare Organizations or another national accrediting body. The HMO shall maintain evidence of current licensure and Medicare certification or national accreditation in the provider´s credentialing file at all times.]

(iii) Evidence of other applicable state or federal requirements, e.g., Bureau of Radiation Control certification for diagnostic imaging centers, Texas Mental Health and Mental Retardation certification for community mental health centers, CLIA (Clinical Laboratory Improvement Amendments of 1988) certification for laboratories; [ If the provider is not Medicare certified or accredited by a national accrediting body, the HMO shall establish written standards for participation, and maintain evidence of evaluation of the provider against those standards in the provider´s credentials file.]

(iv) Evidence of accreditation by a national accrediting body, as applicable; the HMO shall determine which national accrediting bodies are appropriate for different types of institutional providers. The HMO´s written policy and procedures must state which national accrediting bodies it accepts; [ The HMO shall maintain evidence of current licensure and Medicare certification in the provider´s credentialing files at all times.]

(v)Evidence of on-site evaluation of the institutional provider against the HMO´s written standards for participation if the provider is not accredited by the national accrediting body required by the HMO. [ The HMO procedures shall provide for recredentialing of institutional providers at least every three years.]

(F) The HMO procedures shall provide for recredentialing of institutional providers 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.

(G) Under Insurance Code Article 20A.39, the standards adopted in this paragraph must comply with the standards promulgated by the National Committee for Quality Assurance (NCQA) to the extent that those standards do not conflict with other laws of the state. Therefore, if the NCQA standards change and there is a difference between the standards specified in this paragraph and the NCQA standards, the NCQA standards shall prevail to the extent that those standards do not conflict with the other laws of this state.

(5) Site visits for cause.

(A) The HMO shall have procedures for detecting deficiencies subsequent to the initial site visit. When the HMO identifies new deficiencies, the HMO shall reevaluate the site and institute actions for improvement,

(B) An HMO may conduct a site visit to the office of any physician or provider at any time for cause. The site visit to evaluate the complaint or other precipitating event shall be conducted by appropriate personnel and may include, but not be limited to, an evaluation of any facilities or services relating to the complaint or event and an evaluation of medical records, equipment, space, accessibility, appointment availability, or confidentiality practices, as appropriate.

(6) Peer Review. The quality improvement program shall provide for an effective peer review procedure for physicians[ , dentists,] and individual [ other] providers.

[ (7) Measurements, data collection, and analysis. The HMO shall track quality improvement by using measurements, quality improvement data collection and analysis.]

[ (A) To monitor and evaluate aspects of care and services identified, the HMO shall use quality indicators that are objective, measurable, and based on current knowledge and clinical experience.]

[ (B) The HMO shall have performance goals for each indicator.]

[ (8) Methods and frequency of data collection. The HMO shall establish methods and frequency of data collection for each indicator.]

[ (A) Quality improvement activities include the collection of data.]

[ (B) Data collected through monitoring and evaluation activities shall be analyzed.]

[ (i) Appropriate clinicians shall evaluate data on clinical performance of practitioners.]

[ (ii) Multidisciplinary teams shall be used, where indicated, to analyze and address quality improvement issues.]

[ (9) Health promotion.]

[ (A) The HMO shall facilitate preventive health care through health promotion activities. Health promotion activities include outreach to enrollees to encourage appropriate use of services and educating enrollees in preventive health care measures. Outreach may be accomplished through but not limited to written educational materials, community based programs, health promotion fairs, verbal communication, and monetary contributions made to community based organizations and health related initiatives of other programs.]

[ (B) The HMO shall inform and educate physicians and, if applicable, providers such as dentists and physical therapists about using the health management and outreach programs for the enrollees assigned to them.]



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