1. (a) The following documents must be maintained for inspection at all times at the HMO's office located within the State of Texas:

   1. (1) administrative policy manuals; physician and provider manuals; enrollee information; enrollee newsletters; personnel manuals; organizational charts; contracts with physicians and, if applicable, providers such as dentists and physician therapists; and other items as required;
   2. (2) the quality improvement review standards, quality improvement committee meeting minutes, internal quality review audits of each defined service area, quality of care assurance program description, medical peer review committee minutes, and utilization review system program description, including policies and procedures to evaluate medical necessity, criteria used, information sources, the process used to review and approve the provision of medical services and utilization review system data;
   3. (3) the complaint policy and procedure and forms to be used in the complaint resolution procedure. All complaints shall be processed in accordance with the HMO's complaint policy and procedure which shall be developed in accordance with the Insurance Code Chapter 20A.
   4. (4) the accessibility monitoring data;
   5. (5) the enrollee satisfaction surveys, results of surveys and disenrollment and termination logs;
   6. (6) a system for accessing medical, hospital and health records of all enrollees and records of all physicians and other providers providing service under independent contract with an HMO shall be subject to such examination as is necessary for an ongoing examination. The plan shall provide for adequate protection of confidentiality of medical and health care information and shall only be disclosed in accordance with applicable law;
   7. (7) network configuration information, including an explanation of the adequacy of the physician, dentist and other provider network configuration. The information provided must include the names of physicians, referral specialists, and other providers by zip code or zip code map, and indicate whether each physician or other provider is accepting new patients from the HMO;
   8. (8) lists of primary care and referral specialists, hospitals, laboratories, diagnostic imaging providers, radiologic oncology providers, and, if applicable, other providers such as dentists and physical therapists to be used by the applicant inside the service area, including their certification/accreditation and trauma level status as applicable;
   9. (9) current files containing the form or template of all contracts, with copies of signature pages, for all participating physicians and, if applicable, other providers of care such as dentists and physical therapists that are updated on an ongoing basis;
   10. (10) current files containing the form or template of all contracts, with copies of signature pages, on subcontracting physicians and, if applicable, providers such as dentists and physical therapists which contain sufficient information to assure current licensure or other authorizations to practice in the State of Texas;
   11. (11) evidence that the HMO has a mechanism for maintaining, monitoring and implementing the quality improvement program, as required by §11.1902 of this title (relating to Quality Improvement Program) including procedures for data collection, analysis and reporting for all physicians and providers, including pharmacy or drug utilization review format, if applicable; utilization review; denials of coverage and a complaint system as required by this chapter;
   12. (12) current physician manual and current provider manual which shall be provided to each contracting physician and other provider. The manuals shall contain details of the requirements by which the physicians and providers will be governed.
   13. (13) credentialing files as specified in §11.1902(5) of this title;
   14. (14) a copy of all printed materials to be presented to prospective enrollees, an enrollee handbook, an evidence of coverage and physician and provider manuals;
   15. (15) the statistical reporting system developed and maintained by the HMO which allows for compiling, developing, evaluating, and reporting statistics relating to the cost of operation, the pattern of utilization of services, and the accessibility and availability of services;
   16. (16) the HMO's financial statements;
   17. (17) any report submitted by the HMO to the Texas Health Care Information Council;
   18. (18) all complaints and complaint files;
   19. (19) documentation of regular review of complaint reports by management and the governing body;

   20. (20) the complaint and appeal log, including documentation on each complaint received and details of action taken on the complaint. Complaints and appeals must be categorized as follows:

       1. (A) plan administration (e.g., marketing, policyholder service, billing, underwriting or similar administrative functions);
       2. (B) benefit denial or limitation (e.g., denial of a benefit, refusal to refer or provide requested services);
       3. (C) quality of the treating physician, dentist or provider care (e.g., misdiagnoses or lack of courteous treatment);
       4. (D) enrollee services (e.g., lack of courteous treatment; appointment time or waiting room time);
   21. (21) access to appointments (e.g., appointment time or waiting room time);
   22. (22) financial records, including ledgers, checkbooks, inventory records, evidence of expenditures, investments and debts; and
   23. (23) any other records concerning the operation of the HMO.

2. (b) The following documents may be maintained outside the State of Texas if the HMO has received prior approval by the commissioner pursuant to the Insurance Code Article 1.28:

   1. (1) financial records, including ledgers;
   2. (2) checkbooks;
   3. (3) inventory records;
   4. (4) evidence of expenditures, investments, and debts; and
   5. (5) the minutes of the HMO organizational meetings which indicate the type and date of each meeting, and the officer or officers who are responsible for the handling of the funds of the applicant; the minutes of meetings of the HMO board of directors; management committee meeting minutes.

Source Note:The provisions of this §11.205 adopted to be effective January 1, 1980, 4 TexReg 4625; amended to be effective December 6, 1984, 9 TexReg 6008; amended to be effective December 4, 1987, 12 TexReg 4259; amended to be effective August 17, 1992, 17 TexReg 5352; amended to be effective December 8, 1997, 22 TexReg 11684; amended to be effective November 2, 1998, 23 TexReg 11347.