The quality improvement program shall be continuous and comprehensive, including both the quality of clinical care and the quality of service. The HMO shall dedicate adequate resources such as personnel, analytic capabilities, and data resources to the quality improvement program. The HMO shall continuously update and monitor the quality improvement 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 that includes a schedule of activities designed to reflect the population served by the HMO in terms of age groups, disease categories, and special risk status. The work plan shall include but not be limited to the following:

   1. (A) Goals, objectives, and planned projects or activities identified from the previous year, as well as for the current year; time frames for implementation; responsible individuals; and coordination of functions.

   2. (B) Use of quality indicators, performance measurements, and quality improvement data collection to monitor quality improvement.

      1. (i) Quality indicators must be objective, measurable, and include performance goals for each indicator.
      2. (ii) Performance measures must be process or outcome measures.
      3. (iii) Data collected must be appropriate to the goals and objectives of the activity.

   3. (C) Ongoing or periodic assessment of both quality of clinical care and quality of service in planned projects, specifically:

      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, which shall specify methodologies to be used to accomplish them;

      4. (iv) The adoption and annual updating of clinical practice guidelines or clinical care standards, compatible with current principles of health care; the quality improvement program shall assure the practice guidelines:

         1. (I) are approved by participating physicians and individual providers;
         2. (II) are included in physician and provider manuals; and
         3. (III) include preventive health services.
      5. (v) Enrollee, physician, and individual provider satisfaction;
      6. (vi) The complaint and appeal process, complaint data, and identification and removal of communication barriers which may impede enrollees, physicians, and providers from effectively making complaints against the HMO;

      7. (vii) Preventive health care through health promotion and outreach activities:

         1. (I) The HMO shall inform and educate physicians and providers about using the health management and outreach programs for the enrollees assigned to them.
         2. (II) Outreach may be accomplished through, but not limited to, written educational materials, community-based programs and presentations, health promotion fairs, and monetary contributions to community-based organizations and health related initiatives of other programs.
      8. (viii) Claims payment processes;
      9. (ix) Contract monitoring, including delegation oversight and compliance with filing requirements; and
      10. (x) Utilization review processes.

   4. (D) Ongoing or periodic analysis and evaluation of both quality of clinical care and quality of service planned projects specified in subparagraph (C) of this paragraph, which shall include:

      1. (i) Evidence that results of evaluation are used to improve clinical care and services; and
      2. (ii) A systematic method of tracking areas identified for improvement to assure that appropriate action is taken to effect the needed improvement.
3. (3) Evaluation. There shall be an annual written report on the quality improvement program, which includes completed activities, trending of clinical and service indicators, analysis of program performance, conclusions, and demonstrated improvements in care and services.

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) Credentialing is required for all physicians and providers, including advanced practice nurses, and physicians' assistants. Physicians or providers who are members of a contracting group, such as an independent physician association or medical group, shall be credentialed individually.

      2. (ii) Credentialing is not required for:

         1. (I) hospital-based physicians or individual providers, including advanced practice nurses and physicians' 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; or
         4. (IV) pharmacists.
      3. (iii) 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.
      4. (iv) 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).

      5. (v) 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 occurrences of poor quality are identified. Monitoring shall include, but not be limited to:

         1. (I) Medicare and Medicaid sanctions;
         2. (II) Information from state licensing boards regarding sanctions or licensure limitations; and
         3. (III) Complaints.
      6. (vi) If the HMO delegates credentialing functions to other entities, it shall have a process for developing delegation criteria and for performing pre-delegation and annual audits, a delegation agreement, a monitoring plan, and a procedure for termination of the delegation agreement for non-performance. If the HMO delegates credentialing functions to an entity accredited by the National Committee for Quality Assurance, the annual audit of that entity is not required; however, evidence of this accreditation shall be made available to the department for review. The HMO shall maintain documentation of pre-delegation and annual audits, executed delegation agreements, reports received from the delegated entities, current rosters or copies of signed contracts with physicians and providers who are affected by the delegation agreement, and ongoing monitoring and shall make this documentation available to the department for review. Credentialing files maintained by the other entities to whom the HMO has delegated credentialing functions shall be made available to the department for examination upon request. In all cases, the HMO shall maintain the right to approve credentialing, suspension, and termination of physicians and providers.
      7. (vii) 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.
      8. (viii) 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, but not be limited to, the following:

      1. (i) Physicians shall complete the standardized credentialing application adopted in §21.3201 of this title (relating to the Texas Standardized Credentialing Application for Physicians) 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, 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 following shall be verified from primary sources and evidence of verification shall be included 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 the 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's 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. 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, and the source used must be the most recent available.

         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 may be verified 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 Master File.

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

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

         2. (II) Information on previous sanction activity by Medicare and Medicaid which may be obtained 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;

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

      4. (iv) The HMO shall perform a site visit to the offices of each primary care physician, obstetrician-gynecologist, primary care dentist, and high-volume individual behavioral health provider as part of the initial credentialing process. In addition, the HMO shall have written procedures for determining high-volume individual behavioral health providers. If physicians or individual providers are part of a group practice which shares the same office, one visit to the site may be used 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 site visit assessment shall be made available to the department for review.
      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, it shall be determined 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, including professional liability coverage. The process shall also consider performance indicators for primary care and high-volume individual behavioral health care providers, including enrollee complaints and information from quality improvement activities. Recredentialing procedures shall include, but not be limited to, the following processes:

      1. (i) Reverification of the following from the primary sources and in accordance with the same verification time limit as for the initial credentialing process specified in subparagraph (C) of this paragraph:

         1. (I) Licensure and information on sanctions or limitations on licensure;

         2. (II) Board certification:

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

            (-b-) 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

         3. (III) 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:

            (-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 Master File.

      2. (ii) Updated history of professional liability claims, and sanction and restriction information from Medicare and Medicaid 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, Texas Mental Health and Mental Retardation certification for community mental health centers, 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 policy and procedures must state which national accrediting bodies it accepts;
      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)-(v) 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 site visit to evaluate the complaint or other precipitating event shall be conducted by appropriate personnel and may include, but not be limited to, an evaluation of any facilities or services relating 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 quality improvement program shall provide for an effective peer review procedure for physicians and individual 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.