The MCQA Office is made up of knowledgeable staff members who provide assistance to injured employees, enrollees, industry representatives and other members of the public. The MCQA Office also certifies and regulates Utilization Review Agents (URAs), and Independent Review Organizations (IROs), the adequacy of Health Maintenance Organization (HMO) Carriers, Exclusive Provider Benefit Plans (EPBPs), Preferred Provider Benefit Plans (PPBPs), and certified Workers' Compensation Health Care Networks.
Health Maintenance Organizations
On the HMO homepage, you will be able to find a variety of important information, including a listing of HMOs, HMO licensing information, a link to HMO forms and other HMO-related information.
Workers' Compensation Health Care Networks
The Texas Department of Insurance regulates Texas Workers' Compensation Health Care Networks. These networks provide health care services to injured employees through certified health care networks. The MCQA Office is responsible for the certification and regulation of the health care networks. In Texas, an employer may elect to use, but is not required to use, a certified workers' compensation health care network.
The Division of Workers' Compensation oversees the state-regulated insurance program that pays medical bills and replaces some lost wages for employees who are injured at work or who have work-related diseases or illnesses.
Independent Review Organizations
Independent Review Organizations are independent third parties certified by the Texas Department of Insurance to review the utilization reviewer's decision that health care services are not medically necessary or appropriate, or that health care services are experimental or investigational. If a health benefit plan or workers' compensation carrier refuses to pay for a treatment because it does not consider the treatment medically necessary or appropriate, or because it considers the treatment to be experimental or investigational, you may be able to have an IRO review the decision.
Utilization Review Agents
Utilization Review Agents are registered or licensed entities that review requests for health care services being provided (concurrent), proposed to be provided (prospective), or already provided (retrospective). URAs determine whether services are medically necessary and appropriate and may also determine if services are experimental and investigational. The MCQA Office processes applications for entities seeking registration, licensure or licensure renewal as a URA within the state of Texas.
Exclusive Provider Benefit Plan (EPBP) and Preferred Provider Benefit Plan (PPBP) Networks
EPBP and PPBP networks are used by Texas life/health insurers to provide covered benefits to their EPBP and PPBP enrollees.
Provider Network Contracting Entities
Each person operating as a Provider Network Contracting Entity must register with the Texas Department of Insurance.
Third Party Administrator (TPA)
On the Third Party Administrator homepage, you will be able to find a variety of information, including a listing of TPAs, TPA licensing information, a link to TPA forms and other TPA-related information.