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. The credentialing process required by this section 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 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. If the HMO delegates credentialing functions to other entities, its credentialing process 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 this state.

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; amended to be effective November 15, 2006, 31 TexReg 9298.