The applicant must provide information required by the commissioner, which includes, but is not limited to the following:

1. (1) a summary of the independent review plan which meets the requirements of §12.201 of this title (relating to Independent Review Plan) and must include:

   1. (A) a summary description of screening criteria and review procedures to be used to determine medical necessity and appropriateness of health care;
   2. (B) a certification signed by an authorized representative that such screening criteria and review procedures to be applied in review determinations are established with input from appropriate health care providers and approved by physicians in accordance with §12.201(3) of this title (relating to Independent Review Plans); and
   3. (C) procedures ensuring that the information regarding the reviewing physicians and providers is updated in accordance with §12.105(d) of this title (relating to Revisions During Review Process) and §12.108(e) of this title (relating to Renewal of Certificate of Registration) to ensure the independence of each health care provider or physician making review determinations.
2. (2) copies of policies and procedures which ensure that all applicable state and federal laws to protect the confidentiality of medical records and personal information are followed. These procedures must comply with §12.208 of this title (relating to Confidentiality);
3. (3) a certification signed by an authorized representative that the independent review organization will comply with the provisions of the Act;
4. (4) a description of personnel and credentialing, and a completed profile for each physician and provider, both as described in §12.202 of this title (relating to Personnel and Credentialing);
5. (5) a description of hours of operation and how the independent review organization may be contacted after hours, during weekends and holidays, as set forth in §12.207 of this title (relating to Independent Review Organization's Telephone Access);

6. (6) the organizational information, documents and all amendments, including:

   1. (A) the bylaws, rules and regulations, or any similar document regulating the conduct of the internal affairs of the applicant with a notarized certification bearing the original signature of an officer or authorized representative of the applicant that they are true, accurate, and complete copies of the originals;
   2. (B) for an applicant that is publicly held, the name of each stockholder or owner of more than 5.0% of any stock or options;
   3. (C) a chart showing the internal organizational structure of the applicant's management and administrative staff; and
   4. (D) a chart showing contractual arrangements of the independent review system.
7. (7) the name of any holder of bonds or notes of the applicant that exceed $100,000;
8. (8) the name and type of business of each corporation or other organization that the applicant controls or is affiliated with and the nature and extent of the affiliation or control and a chart or list clearly identifying the relationships between the applicant and any affiliates;

9. (9) biographical information about officers, directors, and executives:

   1. (A) the independent review organization must submit the name and biographical information for each director, officer, and executive of the applicant, any entity listed under paragraph (8) of this section, and a description of any relationship the named individual has which represents revenue equal to or greater than 5.0% of that person's total annual revenue or which represents a holding or investment worth $100,000 or more in any of the following entities:

      1. (i) a health benefit plan;
      2. (ii) a health maintenance organization;
      3. (iii) an insurer;
      4. (iv) a utilization review agent;
      5. (v) a nonprofit health corporation;
      6. (vi) a payor;
      7. (vii) a health care provider; or
      8. (viii) a group representing any of the entities described by clauses (i)-(viii) of this subparagraph.
   2. (B) any relationship between the independent review organization and any affiliate or other organization in which an officer, director, or employee of the independent review organization holds a 5.0% or more interest;
   3. (C) a list of any currently outstanding loans or contracts to provide services between the applicant and the affiliates;
10. (10) information related to out-of-state licensure and service of legal process. All applicants must furnish a copy of the certificate of registration or other licensing document from the domiciliary state's licensing authority. As a condition of being certified to conduct the business of independent review in this state, an independent review organization that maintains its principal offices or any portion of its books, records, or accounts outside this state must appoint and maintain a person in this state as attorney for service of process on whom all judicial and administrative process, notices, or demands may be served, and must notify the department of any change of appointment or appointee's address immediately;
11. (11) the percentage of the applicant's revenues that are anticipated to be derived from independent reviews conducted.

Source Note:The provisions of this §12.103 adopted to be effective November 26, 1997, 22 TexReg 11363.