Form No. LHL006 requires information necessary for the commissioner to properly determine whether an applicant is qualified to be certified as an independent review organization pursuant to the Insurance Code §4202.004, including:

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

   1. (A) a summary description of review criteria and review procedures to be used to determine medical necessity or appropriateness of health care;
   2. (B) a summary description of review criteria and review procedures to be used to determine the experimental or investigational nature of health care;
   3. (C) a certification signed by an authorized representative that such review 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 chapter; and
   4. (D) procedures ensuring that the information regarding the reviewing physicians and providers is updated in accordance with §12.105(d) of this subchapter (relating to Revisions During Review Process) and §12.108(e) of this subchapter (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 chapter (relating to Confidentiality);
3. (3) a certification signed by an authorized representative that the independent review organization will comply with the Insurance Code Chapter 4202.
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 chapter (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 chapter (relating to Independent Review Organization 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 five percent 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 applicant.
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, including information requested in Form No. FIN311 (Biographical Affidavit) as required in §12.102(b) of this subchapter (relating to Application and Renewal of Certificate of Registration Form; How to Obtain Forms:

   1. (A) the applicant must submit the name, biographical information, and, in compliance with §1.503 and §1.504 of this title (relating to Application of Fingerprint Requirement and Fingerprint Requirement), a complete set of fingerprints 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 five percent of that individual'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;
      8. (viii) another independent review organization; or
      9. (ix) a group representing any of the entities described by clauses (i) - (viii) of this subparagraph.
   2. (B) the applicant must identify any relationship between the applicant and any affiliate or other organization in which an officer, director, or employee of the applicant holds a five percent or more interest;
   3. (C) the applicant must submit a list of any currently outstanding loans or contracts to provide services between the applicant and any affiliates;
10. (10) for an application for a certificate or renewal of registration as an independent review organization in this state made on or after December 26, 2010, evidence that the applicant's primary office is located in this state. As a condition of being certified to conduct the business of independent review in this state, an independent review organization must locate its primary office in this state;
11. (11) the percentage of the applicant's revenues that are anticipated to be derived from independent reviews conducted; and
12. (12) a disclosure of any enforcement actions related to the provision of medical care or conducting of medical reviews taken against a person subject to the fingerprint requirements under §1.503 and §1.504 of this title.

Source Note:The provisions of this §12.103 adopted to be effective November 26, 1997, 22 TexReg 11363; amended to be effective December 26, 2010, 35 TexReg 11281.