1. (a) The department has authority to conduct examinations of HMOs under Insurance Code §§843.251 and 843.156. Such examinations may be conducted to determine the financial condition ("financial exams"), quality of health care services ("quality of care exams"), or compliance with laws affecting the conduct of business ("market conduct exams" or "complaint exams").
2. (b) On-site financial, market conduct examinations, complaint or quality of care exams shall be conducted pursuant to Insurance Code Article 1.15 and §7.83 of this title (relating to Appeal of Examination Reports).

3. (c) 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, work plans, program evaluations, committee and subcommittee meeting minutes;
   3. (3) utilization management: program description, policies and procedures, criteria used to determine medical necessity, and templates of adverse determination letters; adverse determination logs, including all levels of appeal; and utilization management files;
   4. (4) complaints and appeals: policies and procedures and templates of letters; and complaint and appeal logs, including documentation and details of actions taken. On or after January 1, 2006, all complaints shall be categorized according to §11.205(a)(4)(A) - (J) of this title (relating to Documents to be Available for Qualifying Examinations); and complaint and appeal files;
   5. (5) satisfaction surveys: enrollee, physician and provider satisfaction surveys, enrollee disenrollment and termination logs;
   6. (6) health information systems: policies and procedures for accessing enrollee health records and a plan to provide for confidentiality of those records;
   7. (7) network configuration information as required by §11.204(18) of this title (relating to Contents) demonstrating adequacy of the physician, dentist and provider network;

   8. (8) executed agreements: including:

      1. (A) management services agreements;
      2. (B) administrative services agreements; and
      3. (C) delegation agreements.
   9. (9) executed physician and provider contracts: copy of the first page, including form number, and signature page of individual provider contracts and group provider contracts;
   10. (10) executed subcontracts: copy of the first page, including the form number, and signature page of all contracts with subcontracting physicians and providers;
   11. (11) credentialing: credentialing policies and procedures and credentialing files;
   12. (12) reports: any reports submitted by the HMO to a governmental entity;
   13. (13) claims systems: policies and procedures and systems/processes that demonstrate timely claims payments, and reports that substantiate compliance with all applicable statutes and rules regarding claims payment to physicians, providers and enrollees;
   14. (14) financial records: including statements, ledgers, checkbooks, inventory records, evidence of expenditures, investments and debts; and
   15. (15) other: any other records demonstrating compliance with applicable statutes and rules.

4. (d) Quality of care examinations shall be conducted pursuant to the following protocol:

   1. (1) Entrance conference. The examination team or assigned examiner shall hold an entrance conference with the HMO's key management staff or their designee before beginning the examination.
   2. (2) Interviews. Examination team members or the examiner shall conduct interviews with key management staff or their designated personnel.
   3. (3) Exit conference. Upon completion of the examination, the examination team or examiner shall hold an exit conference with the HMO's key management staff or their designee.
   4. (4) Written report of examination. The examination team or examiner shall prepare a written report of the examination. The department shall provide the HMO with the written report, and if any deficiencies are cited, then the department shall issue a letter outlining the timeframes for the corrective action plan and corrective actions.
   5. (5) Serious deficiencies cited and plan of correction. If the examination team or examiner cites serious deficiencies, the HMO shall provide the examination team or examiner with a signed plan to correct deficiencies within one business day of written notice of deficiencies. The HMO's plan of correction shall allow up to 12 days for correction of the deficiencies in accordance with severity of the deficiencies.
   6. (6) Plan of correction. Except as provided in paragraph (5) of this subsection, if the examination team or examiner cites deficiencies, then the HMO shall provide a signed plan of correction to the department no later than 30 days from receipt of the written examination report. The HMO's plan must provide for correction of these deficiencies no later than 90 days from the receipt of the written examination report.
   7. (7) Verification of correction. The department shall verify the correction of deficiencies by submitted documentation or by on-site examination.

Source Note:The provisions of this §11.303 adopted to be effective November 2, 1998, 23 TexReg 11347; amended to be effective February 24, 2005, 30 TexReg 854.