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Numeric Listing of Managed Care Quality Assurance Forms

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TDI Form Number Description File Format Language
FIN306 Officers and Directors Page
Complete Listing of all Current Officers and Directors 		PDF English
LHL005 URA Application Form
Application to apply for URA Certification, renew a URA Certification or update a URA Certification. 		PDF English
LHL006 IRO Application
Application to apply for IRO Certification, renew an IRO Certification or update an IRO Certification 		PDF English
LHL007 Supplemental Certification for IRO Renewal
Attach this form to the renewal application. You can attach it in the online renewal form or with the IRO Application, Form LHL006. 		PDF English
LHL009 Request for Review by an IRO
Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity 		PDF English
LHL009 Spanish Solicitud para una revisión por parte de una Organización de Revisión Independiente
[En Español] - Solicitud para pedir una revisión por parte de una Organización de Revisión Independiente (Independent Review Organization- IRO por su nombre y siglas en inglés) para las disputas médicas necesarias de pacientes, empleados lesionados, representantes del paciente o proveedores de atención médica. 		PDF Spanish
LHL011 Notice of Rescission of Preauthorization Exemption and Right to Request an Independent Review
 PDF English
LHL234 Application Package
 PDF English
LHL234a Other Professional Degrees
Attachment A 		PDF English
LHL234b Other Post-Graduate Education
Attachment B 		PDF English
LHL234c Other Work History
Attachment C 		PDF English
LHL234d Other Current Hospital Affiliations
Attachment D 		PDF English
LHL234e Other Previous Hospital Affiliations
Attachment E 		PDF English
LHL234f Other Practice Locations
Attachment F 		PDF English
LHL234g Malpractice Claims History
Attachment G 		PDF English
LHL658 Application for Approval Exclusive Provider Benefit Plan (EPO) and Preferred Provider Benefit Plan (PPO)
 PDF English
LHL705 Workers’ Compensation Health Care Network Application
 PDF English
LHL706 Preferred Provider Benefit Plan (PPBP) and Exclusive Provider Benefit Plan (EPBP), Annual Report, Waiver Request, and Access Plan Checklist
 PDF English
LHL707 HMO Network Access Plan Requirements
 PDF English
LHL708 Workers' Compensation Network Access Plan Checklist
WC Network Access Plan Checklist 		PDF English
LHL709 Certification of Independence and Qualifications of the Reviewer
 PDF English
LHL710 Holder of Bonds or Notes Over $100,000
 PDF English
LHL711 Addendum to Biographical Affidavit
 PDF English
LHL712 IRO Notice of Decision Template - HC
 WORD English
LHL713 IRO Notice of Decision Template - WC
 WORD English
LHL715 Provider Network Contracting Entity Registration and Exemption of Affiliates Form
PNCE Registration and Exemption Form 		PDF English
LHL716 Health Maintenance Organization Annual Network Adequacy Report and Access Plan Checklist
 PDF English
LHL717 Utilization Review Agent's (URA) Designated Contact for IRO Requests
 PDF English
LHL718 Health Maintenance Organization (HMO) Physician / Provider Contract Requirements
Used as guide to indicate the mandatory provisions and benefits required in a Provider Contract 		PDF English
LHL719 HMO Delegation Agreement Checklist
 PDF English
LHL720 Workers' Compensation Health Care Network Provider Contract Checklist
 PDF English
LHL721 Workers’ Compensation Network Contract with Insurance Carrier Contract Requirements Checklist
 PDF English
LHL722 Workers' Compensation Health Care Network Management Contract Checklist
 PDF English
NOFR001 Prior Authorization of Health Care Services
 PDF English
NOFR002 Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
 PDF English
SN002 Notice to HMO Enrollees: Have a complaint about your HMO?
 PDF English
SN002s ¿Tiene una queja relacionada con su HMO?
 PDF Spanish
SN003 Workers Comp Network Sample Contingency Plan
 PDF English
SN004 Workers Comp Net Sample Employee Acknowledgment Form
 PDF English
SN005 Workers Comp Net Employee Acknowledgment Form
PDF Spanish
SN006 Workers Comp Net Sample Employee Acknowledgment Form - Chinese
 PDF Chinese
SN007 Workers Comp Net Sample Employee Acknowledgment Form
 PDF Vietnamese
SN008 Workers Comp Network Sample QI Report
 PDF English
SN009 Sample URA Adverse Determination Notice, Health
 PDF English
SN010 Sample URA Adverse Determination Notice, Specialty Health
PDF English
SN011 Sample URA Adverse Determination Notice, Workers Comp Net
 PDF English
SN012 Sample URA Adverse Determination Notice, Workers Comp Non-Network
 PDF English
SN013 Contract List
 PDF English
SN014 Delegated Entity Data Form
Sample format for use by HMOs and WC HCNs when submitting delegation agreements to the Texas Department of Insurance 		PDF English
SN016 Sample Network Adequacy Contracted Provider List
 EXCEL English
SN017 Sample Network Adequacy Access Plan
 EXCEL English

For more information, contact: MCQA@tdi.texas.gov