The QI program for basic and limited services HMOs shall be continuous and comprehensive, addressing both the quality of clinical care and the quality of services. The HMO shall dedicate adequate resources, such as personnel and information systems, to the QI program.

1. (1) Written description. The QI program shall include a written description of the QI program that outlines program organizational structure, functional responsibilities, and meeting frequency.

2. (2) Work plan. The QI program shall include an annual QI work plan designed to reflect the type of services and the population served by the HMO in terms of age groups, disease categories, and special risk status. The work plan shall include:

   1. (A) Objective and measurable goals; planned activities to accomplish the goals; time frames for implementation; responsible individuals; and evaluation methodology.

   2. (B) The work plan shall address each program area, including:

      1. (i) Network adequacy, which includes availability and accessibility of care, including assessment of open/closed physician and individual provider panels;
      2. (ii) Continuity of health care and related services;
      3. (iii) Clinical studies;

      4. (iv) The adoption and periodic updating of clinical practice guidelines or clinical care standards; the QI program shall assure the practice guidelines:

         1. (I) are approved by participating physicians and individual providers;
         2. (II) are communicated to physicians and individual providers; and
         3. (III) include preventive health services;
      5. (v) Enrollee, physician, and individual provider satisfaction;
      6. (vi) The complaint and appeals process, complaint data, and identification and removal of communication barriers that may impede enrollees, physicians, and providers from effectively making complaints against the HMO;
      7. (vii) Preventive health care through health promotion and outreach activities;
      8. (viii) Claims payment processes;
      9. (ix) Contract monitoring, including delegation oversight and compliance with filing requirements;
      10. (x) Utilization review processes;
      11. (xi) Credentialing;
      12. (xii) Member services; and
      13. (xiii) Pharmacy services, including drug utilization.
3. (3) Evaluation. The QI program shall include an annual written report on the QI program, which includes completed activities, trending of clinical and service goals, analysis of program performance, and conclusions.

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

   1. (A) The HMO's policies and procedures shall clearly indicate the physician or individual provider directly responsible for the credentialing program and shall include a description of his or her participation.

   2. (B) HMOs shall develop written criteria for credentialing of physicians and providers and written procedures for verifications.

      1. (i) The HMO shall credential all physicians and providers, including advanced practice nurses, and physician assistants, if they are listed in the provider directory. An HMO shall credential each physician or individual provider who is a member of a contracting group, such as an independent physician association or medical group.

      2. (ii) Policies and procedures must include the following physicians' and providers' rights:

         1. (I) the right to review information submitted to support the credentialing application;
         2. (II) the right to correct erroneous information;
         3. (III) the right, upon request, to be informed of the status of the credentialing or recredentialing application; and
         4. (IV) the right to be notified of these rights.

      3. (iii) An HMO is not required to credential:

         1. (I) hospital-based physicians or individual providers, including advanced practice nurses and physician assistants unless listed in the provider directory;
         2. (II) individual providers who furnish services only under the direct supervision of a physician or another individual provider except as specified in clause (i) of this subparagraph;
         3. (III) students, residents, or fellows;
         4. (IV) pharmacists; or
         5. (V) opticians.
      4. (iv) An HMO must complete the initial credentialing process, including application, verification of information, and a site visit (if applicable), before the effective date of the initial contract with the physician or provider.
      5. (v) Policies and procedures shall include a provision that applicants be notified of the credentialing or recredentialing decision no later than 60 calendar days after the credentialing committee's decision.
      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 Insurance Code §§843.306 - 843.309.

      7. (vii) The HMO shall have a procedure for the ongoing monitoring of physician and provider performance between periods of recredentialing and shall take appropriate action when it identifies occurrences of poor quality. Monitoring shall include:

         1. (I) Medicare and Medicaid sanctions: the HMO must determine the publication schedule or release dates applicable to its physician and provider community; the HMO is responsible for reviewing the information within 30 calendar days of its release;
         2. (II) Information from state licensing boards regarding sanctions or licensure limitations; and
         3. (III) Complaints.
      8. (viii) 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. Procedures shall also include a provision that credentialing and recredentialing decisions are not based solely on an applicant's race, ethnic/national identity, gender, age, sexual orientation or the types of procedures or types of patients.
      9. (ix) The HMO shall have a procedure for notifying licensing or other appropriate authorities when a physician's or provider's affiliation is suspended or terminated due to quality of care concerns.

   3. (C) Initial credentialing process for physicians and individual providers shall include the following:

      1. (i) Physicians, advanced practice nurses and physician assistants shall complete the standardized credentialing application adopted in §21.3201 of this title (relating to the Texas Standardized Credentialing Application for Physicians, Advanced Practice Nurses and Physician Assistants) and individual providers shall complete an application which includes a work history covering at least five years, 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, sanctions or other disciplinary activity, lack of current illegal drug use, current professional liability insurance coverage information, and information on whether the individual provider will accept new patients from the HMO. This does not preclude an HMO from using the standardized credentialing application form specified in §21.3201 of this title for credentialing of individual providers. The completion date on the application shall be within 180 calendar days prior to the date the credentialing committee deems a physician or individual provider eligible for initial credentialing.

      2. (ii) The HMO shall verify the following from primary sources and shall include evidence of verification in the credentialing files:

         1. (I) A current license to practice in the State of Texas and information on sanctions or limitations on licensure. The primary source for verification shall be the state licensing agency or board for Texas, and the license and sanctions must be verified within 180 calendar days prior to the date the credentialing committee deems a physician or individual provider eligible for initial credentialing. The license must be in effect at the time of the credentialing decision.
         2. (II) Education and training, including evidence of graduation from an appropriate professional school and completion of a residency or specialty training, if applicable. Primary source verification shall be sought from the appropriate schools and training facilities or the American Medical Association MasterFile. If the state licensing board, agency, or specialty board verifies education and training with the physician's or individual provider's schools and facilities, evidence of current state licensure or board certification shall also serve as primary source verification of education and training.
         3. (III) Board certification, if the physician or individual provider indicates that he/she is board certified on the application. The HMO may obtain primary source verification from the American Board of Medical Specialties Compendium, the American Osteopathic Association, the American Medical Association MasterFile, or from the specialty boards, and the HMO must use the most recent available source.

         4. (IV) Valid Drug Enforcement Agency (DEA) or Department of Public Safety (DPS) Controlled Substances Registration Certificate, if applicable. These must be in effect at the time of the credentialing decision, and the HMO may verify them by any one of the following means:

            (-a-) copy of the DEA or DPS certificate;

            (-b-) visual inspection of the original certificate;

            (-c-) confirmation with DEA or DPS;

            (-d-) entry in the National Technical Information Service database; or

            (-e-) entry in the American Medical Association Physician MasterFile.

      3. (iii) The HMO shall verify within 180 calendar days prior to the date of the credentialing decision and shall include in the physician's or individual provider's credentialing file the following:

         1. (I) Past five-year history of professional liability claims that resulted in settlements or judgments paid by or on behalf of the physician or individual provider, which the HMO may obtain from the professional liability carrier or the National Practitioner Data Bank;

         2. (II) Information on previous sanction activity by Medicare and Medicaid which the HMO may obtain from one of the following:

            (-a-) National Practitioner Data Bank;

            (-b-) Cumulative Sanctions Report available over the internet;

            (-c-) Medicare and Medicaid Sanctions and Reinstatement Report distributed to federally contracting HMOs;

            (-d-) state Medicaid agency or intermediary and the Medicare intermediary;

            (-e-) Federation of State Medical Boards;

            (-f-) Federal Employees Health Benefits Program department record published by the Office of Personnel Management, Office of the Inspector General; or

            (-g-) entry in the American Medical Association Physician MasterFile.

      4. (iv) The HMO shall perform a site visit to the offices of each primary care physician or individual primary care provider, obstetrician-gynecologist, primary care dentist, and high-volume behavioral health physician or individual behavioral health provider as part of the initial credentialing process. In addition, the HMO shall have written procedures for determining high-volume behavioral health physicians or individual behavioral health providers. If physicians or individual providers are part of a group practice that shares the same office, the HMO may perform one visit to the site for all physicians or individual providers in the group practice, as well as for new physicians or individual providers who subsequently join the group practice. The HMO shall make the site visit assessment available to the department for review. The HMO shall have a process to track the relocation of and the opening of additional office sites for primary care physicians and individual primary care providers, obstetrician-gynecologists, primary care dentists, and high-volume behavioral health physicians or individual behavioral health providers as they open.
      5. (v) Site visits shall consist of an evaluation of the site's accessibility, appearance, appointment availability, and space, using standards approved by the HMO. If a physician or individual provider offers services that require certification or licensure, such as laboratory or radiology services, the physician or individual provider shall have the current certification or licensure available for review at the site visit. In addition, as a result of the site visits, the HMO shall determine whether the site conforms to the HMO's standards for record organization, documentation, and confidentiality practices. Should the site not conform to the HMO's standards, the HMO shall require a corrective action plan and perform a follow-up site visit every six months until the site complies with the standards.

   4. (D) The HMO shall have written procedures for recredentialing physicians and individual providers at least every three years through a process that updates information obtained in initial credentialing.

      1. (i) Recredentialing will include a current and signed attestation that must be completed within 180 days prior to the date the credentialing committee deems a physician or individual provider eligible for recredentialing with the following factors:

         1. (I) reasons for any inability to perform the essential functions of the position, with or without accommodation;
         2. (II) lack of current illegal drug use;
         3. (III) history of loss or limitation of privileges or disciplinary activity;
         4. (IV) current professional liability insurance coverage; and
         5. (V) correctness and completeness of the application.

      2. (ii) Recredentialing procedures must be completed within 180 days prior to the date the credentialing committee deems a physician or individual provider eligible for recredentialing and shall include the following processes:

         1. (I) Reverification of the following from the primary sources:

            (-a-) Licensure and information on sanctions or limitations on licensure;

            (-b-) Board certification:

            (-1-) if the physician or individual provider was due to be recertified; or

            (-2-) if the physician or individual provider indicates that he or she has become board certified since the last time he or she was credentialed or recredentialed; and

            (-c-) Drug Enforcement Agency (DEA) or Department of Public Safety (DPS) Controlled Substances Registration Certificate, if applicable. These may be reverified by any one of the following means:

            (-1-) copy of the DEA or DPS certificate;

            (-2-) visual inspection of the original certificate;

            (-3-) confirmation with DEA or DPS;

            (-4-) entry in the National Technical Information Service database; or

            (-5-) entry in the American Medical Association Physician MasterFile.

         2. (II) Review of updated history of professional liability claims in accordance with the verification sources and time limits specified in subparagraph (C)(iii) of this paragraph.

   5. (E) The credentialing process for institutional providers shall include the following:

      1. (i) Evidence of state licensure;
      2. (ii) Evidence of Medicare certification;
      3. (iii) Evidence of other applicable state or federal requirements, e.g., Bureau of Radiation Control certification for diagnostic imaging centers, certification for community mental health centers from the Texas Department of Mental Health and Mental Retardation or its successor agency, CLIA (Clinical Laboratory Improvement Amendments of 1988) certification for laboratories;
      4. (iv) Evidence of accreditation by a national accrediting body, as applicable; the HMO shall determine which national accrediting bodies are appropriate for different types of institutional providers. The HMO's written policies and procedures must state which national accrediting bodies it accepts; and
      5. (v) Evidence of on-site evaluation of the institutional provider against the HMO's written standards for participation if the provider is not accredited by the national accrediting body required by the HMO.
   6. (F) The HMO procedures shall provide for recredentialing of institutional providers at least every three years through a process that updates information obtained for initial credentialing as set forth in subparagraph (E)(i) - (iv) of this paragraph.
   7. (G) Under Insurance Code Article 20A.39, the standards adopted in this paragraph must comply with the standards promulgated by the National Committee for Quality Assurance (NCQA) to the extent that those standards do not conflict with other laws of the state. Therefore, if the NCQA standards change and there is a difference between the standards specified in this paragraph and the NCQA standards, the NCQA standards shall prevail to the extent that those standards do not conflict with the other laws of this state.

5. (5) Site visits for cause.

   1. (A) The HMO shall have procedures for detecting deficiencies subsequent to the initial site visit. When the HMO identifies new deficiencies, the HMO shall reevaluate the site and institute actions for improvement.
   2. (B) An HMO may conduct a site visit to the office of any physician or provider at any time for cause. The HMO shall conduct the site visit to evaluate the complaint or other precipitating event, which may include an evaluation of any facilities or services related to the complaint or event and an evaluation of medical records, equipment, space, accessibility, appointment availability, or confidentiality practices, as appropriate.
6. (6) Peer Review. The QI program shall provide for a peer review procedure for physicians and individual providers, as required in the Medical Practice Act, Chapters 151-164, Occupations Code. The HMO shall designate a credentialing committee that uses a peer review process to make recommendations regarding credentialing decisions.

7. (7) Delegation of Credentialing.

   1. (A) If the HMO delegates credentialing functions to other entities, it shall have:

      1. (i) a process for developing delegation criteria and for performing pre-delegation and annual audits;
      2. (ii) a delegation agreement;
      3. (iii) a monitoring plan; and
      4. (iv) a procedure for termination of the delegation agreement for non-performance.
   2. (B) If the HMO delegates credentialing functions to an entity accredited by the NCQA, the annual audit of that entity is not required for the function(s) listed in the NCQA accreditation; however, evidence of this accreditation shall be made available to the department for review.

   3. (C) The HMO shall maintain:

      1. (i) documentation of pre-delegation and annual audits;
      2. (ii) executed delegation agreements;
      3. (iii) semi-annual reports received from the delegated entities;
      4. (iv) evidence of evaluation of the reports;
      5. (v) current rosters or copies of signed contracts with physicians and individual providers who are affected by the delegation agreement; and
      6. (vi) documentation of ongoing monitoring and shall make it available to the department for review.
   4. (D) Credentialing files maintained by the other entities to which the HMO has delegated credentialing functions shall be made available to the department for examination upon request.
   5. (E) In all cases, the HMO shall maintain the right to approve credentialing, suspension, and termination of physicians and providers.

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; amended to be effective July 31, 2002, 27 TexReg 6701; amended to be effective February 24, 2005, 30 TexReg 854.