Managed Care Quality Assurance Other Forms

Managed Care Quality Assurance Main Forms Listing

Managed Care Quality Assurance Other Forms
TDI Form Number	Description	File Format	Language
FIN306	Officers and Directors Page Complete Listing of all Current Officers and Directors	PDF	English
LHL658	Application for Approval Exclusive Provider Benefit Plan (EPO) and Preferred Provider Benefit Plan (PPO)	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
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
LHL719	HMO Delegation Agreement Checklist	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