1. (a) The following documents must be available for review at the HMO's office located within the State of Texas:

   1. (1) administrative: policy and procedure manuals; physician and provider manuals; enrollee materials; organizational charts; key personnel information, e.g., resumes and job descriptions; and other items as requested;
   2. (2) quality improvement: program description and work plan as required by §11.1902 of this title (relating to Quality Improvement Program for Basic and Limited Services HMOs);
   3. (3) utilization management: program description, policies and procedures, criteria used to determine medical necessity, and examples of adverse determination letters, adverse determination logs, and IRO logs;

   4. (4) complaints and appeals: policies and procedures, examples of letters and examples of complaint and appeal logs. On or after January 1, 2006, each complaint shall be categorized as one or more of the following types of complaint:

      1. (A) quality of care or services;
      2. (B) accessibility/availability of services;
      3. (C) utilization review or management;
      4. (D) complaint procedures;
      5. (E) physician and provider contracts;
      6. (F) group subscriber contracts;
      7. (G) individual subscriber contracts;
      8. (H) marketing;
      9. (I) claims processing; and
      10. (J) miscellaneous;
   5. (5) health information systems: policies and procedures for accessing enrollee health records and a plan to provide for confidentiality of those records in accordance with applicable law;
   6. (6) network configuration information, as outlined in §11.204(18) of this title (relating to Contents) demonstrating adequacy of the physician, dentist and provider network;

   7. (7) executed agreements, including:

      1. (A) management services agreements;
      2. (B) administrative services agreements; and
      3. (C) delegation agreements;
   8. (8) executed physician and provider contracts: copy of the first page, including the form number, and signature page of individual provider contracts and group provider contracts;
   9. (9) executed subcontracts: copy of the first page, including the form number, and signature page of all contracts with subcontracting physicians and providers;
   10. (10) 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;
   11. (11) credentialing files: as specified in §11.1902(4) of this title (relating to Quality Improvement Program for Basic and Limited Services HMOs) and §11.2207(d)(4) of this title (relating to Quality Improvement Structure and Program for Single Service HMOs);
   12. (12) a copy of all printed materials to be presented to prospective enrollees, an enrollee handbook, and an evidence of coverage;
   13. (13) 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;
   14. (14) claims systems: policies and procedures that demonstrate the capacity to pay claims timely and to comply with all applicable statutes and rules;
   15. (15) financial records: including statements, ledgers, checkbooks, inventory records, evidence of expenditures, investments and debts; and
   16. (16) any other records demonstrating compliance with applicable statutes and rules, including audits or examination reports by other entities, including governmental authorities or accrediting agencies.

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 Insurance Code §803.003:

   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; amended to be effective February 24, 2005, 30 TexReg 854.