The quality improvement program shall be continuous and comprehensive including both the quality of clinical care and the quality of service requiring updates as needed. The HMO shall dedicate resources such as personnel, analytic capabilities, and data resources to the program that are adequate to meet the needs of the program.

1. (1) Written description. There shall be a written description of the quality improvement program that outlines program organizational structure, functional responsibility and design.

2. (2) Work plan. There shall be an annual quality improvement work plan, or schedule of activities, that includes but is not limited to the following:

   1. (A) objectives, scope, and planned projects or activities for the year;
   2. (B) planned monitoring of previously identified issues, including tracking of issues over time; and
   3. (C) planned evaluation and modification, if necessary, of the quality improvement program.

3. (3) Monitoring and evaluation. The program monitoring and evaluation of clinical issues shall reflect the population served by the HMO in terms of age groups, disease categories, and special risk status. Monitoring and evaluation of clinical issues shall include:

   1. (A) care and services provided in institutional settings;
   2. (B) care and services provided in noninstitutional settings, including, but not limited to, practitioner offices and home and community support services agencies; and
   3. (C) primary care and major specialty services, including but not limited to mental health, cancer, burn or cardiac centers.
4. (4) Identifying special needs. The quality improvement program shall identify enrollees with special needs such as disabilities and chronic conditions in order to assist the HMO in facilitating the development and implementation of appropriate courses of care to assure that health care services are available and accessible.

5. (5) Credentialing. An HMO shall implement a documented process for selection and retention of affiliated providers, which includes the following elements, as applicable:

   1. (A) HMOs shall develop written criteria for credentialing of physicians and providers appropriate to the nature of the services to be furnished to enrollees. HMOs shall also develop written procedures for verifications.

      1. (i) The governing body shall approve the policies and procedures.
      2. (ii) The policies and procedures shall be evaluated by practicing physicians and providers on at least an annual basis.
      3. (iii) Credentialing shall be required for all physicians and other providers who are permitted to practice independently under state law. Except for advanced practice nurses and physicians' assistants, credentialing is not required for: providers who furnish services only under the direct supervision of a physician or provider; hospital-based physicians or providers who provide services incident to hospital services, unless those physicians or providers are separately identified in enrollee materials as available to enrollees. Students, residents, or fellows do not require credentialing. Physicians or providers who are members of a contracting group shall be credentialed individually.
      4. (iv) The initial credentialing process, including application, verification of information, and a site visit (if applicable), must be completed before the effective date of the initial contract with the physician or provider.
      5. (v) Information collected pursuant to subparagraphs (B)(ii) and (iii) of this paragraph must be no more than six months old on the date on which the physician, dentist, or provider is determined to be eligible for contract by a peer review or credentialing committee, with the exception of information relating to the site visit and medical record review, which shall be no more than two years old.
      6. (vi) An HMO shall have written policies and procedures for suspending or terminating affiliation with a contracting physician or provider, including an appeals process, pursuant to the Insurance Code Article 20A.18A(b).
      7. (vii) The HMO shall have written procedures for recredentialing at least every two years through a process that updates information obtained in initial credentialing and considers performance indicators. The HMO shall maintain documentation of current state licensure and required permits to practice.
      8. (viii) If the HMO delegates the credentialing functions to other entities, it shall have written procedures for delegation of credentialing functions to other entities which include, but are not limited to, criteria for delegation, pre-delegation audit procedure and criteria, delegation agreement, monitoring plan, and a procedure for termination of the delegation agreement for non-performance. Documentation of pre-delegation evaluations performed, executed delegation agreements, reports received from the delegated entities, current rosters or copies of signed contracts of physicians and providers who are affected by the delegation agreement, and continuing monitoring evaluations shall be maintained by the HMO and made available to the department for review. Credentialing files at the delegated entity shall be made available to the department for examination upon request.
      9. (ix) The HMO's procedures shall ensure that selection and retention criteria do not discriminate against physicians or providers who serve high-risk populations or who specialize in the treatment of costly conditions.
      10. (x) The HMO's procedures shall include a procedure for notifying licensing or disciplinary bodies or other appropriate authorities when a practitioner's or provider's affiliation is suspended or terminated due to quality deficiencies.

   2. (B) Initial credentialing process for physicians and individual providers shall include, but not be limited to, the following:

      1. (i) The applicant shall complete an application for affiliation. The application shall include a work history covering at least five years and a statement by the applicant regarding any limitations in ability to perform the functions of the position, history of loss of license and/or felony convictions; and history of loss or limitation of privileges or disciplinary activity. The application shall also include whether the physician will accept new patients from the HMO.

      2. (ii) The following shall be verified from primary sources and included in credentialing files:

         1. (I) A current valid license to practice in the State of Texas. The primary source for verification shall be the state licensing agency or board for Texas.
         2. (II) If applicable, clinical privileges in good standing at the hospital designated by the physician or dentist as the primary network admitting facility. The primary source for verification shall be the hospital.
         3. (III) Education and training, including evidence of graduation from the appropriate professional school and completion of a residency or specialty training, if applicable. Primary source verification shall be sought from the appropriate schools, training facilities or the American Medical Association's MasterFile. If the state licensing board or agency verifies education and training with the physician or provider's schools and facilities, evidence of current state licensure shall also serve as primary source verification of education and training.
         4. (IV) Board certification, if the physician or provider states that he/she is board certified on the application. Primary source verification may be obtained from the American Board of Medical Specialties Compendium, the American Osteopathic Association, the American Medical Association MasterFile, or from the specialty boards.

      3. (iii) The following shall also be included in the physician or individual provider's credentialing file:

         1. (I) Malpractice history from the National Practitioner Data Bank;
         2. (II) Information on previous sanction activity by Medicare and Medicaid;
         3. (III) Copy of a valid Drug Enforcement Agency (DEA) and Department of Public Safety Controlled Substance permit, if applicable;
         4. (IV) Evidence of current, adequate malpractice insurance meeting the HMO's requirements;
         5. (V) Information about sanctions or limitations on licensure from the applicable state licensing agency or board.
      4. (iv) The HMO shall perform a site visit to the offices of each primary care physician, or primary care dentist, as part of the initial credentialing process. In addition, the HMO shall have written procedures for determining the high-volume physicians and non-institutional providers. If physicians or providers are part of a group practice which shares the same office, one visit to the site may be used for all physicians and providers in that office as long as medical records for each physician or provider are sampled.
      5. (v) Site visits shall be conducted by clinical personnel (or teams including clinical personnel), and shall consist of an evaluation of the site's accessibility, appearance, and space, and of the adequacy of equipment, using standards developed by the HMO. In addition, as a result of the site visits, it shall be determined whether the site conforms to the HMO's standards for medical or dental record keeping practices and confidentiality requirements.

   3. (C) Recredentialing procedures for physicians and individual providers shall include, but not be limited to, the following processes:

      1. (i) The following shall be reverified from primary sources:

         1. (I) Licensure;
         2. (II) Clinical privileges;
         3. (III) Board certification only if the physician or dentist was due to be recertified or states that he or she has become board certified since the last time he or she was credentialed or recredentialed.
      2. (ii) The HMO shall requery the National Practitioner Data Bank and obtain updated sanction or restriction information from licensing agencies, Medicare, and Medicaid.
      3. (iii) Site visits conducted by clinical personnel (or teams including clinical personnel) shall be repeated for primary care physicians and high-volume physicians and providers. Multi-practitioner sites should be visited every two years. Medical record audits, including evaluation of the quality of encounter notes, shall be performed within the two years prior to recredentialing.

   4. (D) Credentialing process for institutional providers shall include, but not be limited to, the following:

      1. (i) The HMO procedure shall require evidence of state licensure, and of compliance with any other applicable state or federal requirements.
      2. (ii) The HMO procedure may require evidence of Medicare certification, as applicable, or accreditation by the Joint Commission on Accreditation of Healthcare Organizations or another national accrediting body. The HMO shall maintain evidence of current licensure and Medicare certification or national accreditation in the provider's credentialing file at all times.
      3. (iii) If the provider is not Medicare certified or accredited by a national accrediting body, the HMO shall establish written standards for participation, and maintain evidence of evaluation of the provider against those standards in the provider's credentials file.
      4. (iv) The HMO shall maintain evidence of current licensure and Medicare certification in the provider's credentialing files at all times.
      5. (v) The HMO procedures shall provide for recredentialing of institutional providers at least every three years.
6. (6) Peer review. The quality improvement program shall provide for an effective peer review procedure for physicians, dentists and other providers.

7. (7) Measurements, data collection, and analysis. The HMO shall track quality improvement by using measurements, quality improvement data collection and analysis.

   1. (A) To monitor and evaluate aspects of care and services identified, the HMO shall use quality indicators that are objective, measurable, and based on current knowledge and clinical experience.
   2. (B) The HMO shall have performance goals for each indicator.

8. (8) Methods and frequency of data collection. The HMO shall establish methods and frequency of data collection for each indicator.

   1. (A) Quality improvement activities include the collection of data.

   2. (B) Data collected through monitoring and evaluation activities shall be analyzed.

      1. (i) Appropriate clinicians shall evaluate data on clinical performance of practitioners.
      2. (ii) Multidisciplinary teams shall be used, where indicated, to analyze and address quality improvement issues.

9. (9) Health promotion.

   1. (A) The HMO shall facilitate preventive health care through health promotion activities. Health promotion activities include outreach to enrollees to encourage appropriate use of services and educating enrollees in preventive health care measures. Outreach may be accomplished through but not limited to written educational materials, community based programs, health promotion fairs, verbal communication, and monetary contributions made to community based organizations and health related initiatives of other programs.
   2. (B) The HMO shall inform and educate physicians and, if applicable, providers such as dentists and physical therapists about using the health management and outreach programs for the enrollees assigned to them.

Source Note:The provisions of this §11.1902 adopted to be effective December 8, 1997, 22 TexReg 11684; amended to be effective November 2, 1998, 23 TexReg 11347.