Managed Care Quality Assurance Other 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 |
English | |
LHL658 |
Application for Approval Exclusive Provider Benefit Plan (EPO) and Preferred Provider Benefit Plan (PPO) |
English | |
LHL706 |
Preferred Provider Benefit Plan (PPBP) and Exclusive Provider Benefit Plan (EPBP), Annual Report, Waiver Request, and Access Plan Checklist |
English | |
LHL707 |
HMO Network Access Plan Requirements |
English | |
LHL715 |
Provider Network Contracting Entity Registration and Exemption of Affiliates Form PNCE Registration and Exemption Form |
English | |
LHL716 |
Health Maintenance Organization Annual Network Adequacy Report and Access Plan Checklist |
English | |
LHL719 |
HMO Delegation Agreement Checklist |
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