SECTION 13.415. Documents to be Available for Quality of Care and Financial Examinations

(a) The following documents must be provided to the department on request and available for review at the HCC's office located within Texas:

(1) administrative: policy and procedure manuals, including procedures relating to confidentiality; patient materials; organizational charts; and key personnel information, such as resumes and job descriptions;

(2) quality improvement: program description and work plan as required by §13.481 of this title (relating to Quality Improvement Structure for HCCs); and, to support requirements under §13.482 of this title (relating to Quality Assurance and Quality Improvement) for certified HCCs, program evaluations and meeting minutes for committees and subcommittees;

(3) utilization management: program description; policies and procedures; criteria used to determine medical necessity; templates of adverse determination letters and adverse determination logs for all levels of appeal, or, for certified HCCs, examples of those letters and logs; and, for certified HCCs, utilization management files;

(4) complaints and appeals: policies and procedures; and templates of letters, complaint logs, and appeal logs, or, for certified HCCs, examples of those letters and logs, including documentation and details of actions taken;

(5) health information systems: policies and procedures for accessing patient health records and a plan to provide for confidentiality of those records in accord with applicable law;

(6) network configuration information: as outlined in and required by §13.413(e)(2) of this title (relating to Contents of the Application), demonstrating adequacy of the physician and health care provider network;

(7) executed agreements, including:

(A) contracts with payors;

(B) management services agreements;

(C) administrative services agreements; and

(D) delegation agreements;

(8) executed participant contracts: copy of the first page, including the form number, and signature page of individual and group contracts;

(9) executed subcontracts: copy of the first page, including the form number, and signature page of all contracts with subcontracting physicians and providers;

(10) physician and health care provider manuals: current physician manual and current health care provider manual, which must be provided to each contracting physician and health care provider, respectively, and which must contain details of the requirements by which the physicians and health care providers will be governed;

(11) credentialing documentation: credentialing policies, procedures, and files that demonstrate compliance with §13.483 of this title (relating to Credentialing);

(12) reporting system: the statistical reporting system developed and maintained by the HCC that allows for compiling, developing, evaluating, and reporting statistics relating to the cost of operation, the pattern of utilization of services, and the accessibility and availability of services; and, for certified HCCs, reports generated by the system concerning those components;

(13) claims systems: policies and procedures that demonstrate the capacity to pay claims timely, if applicable, and to comply with all applicable statutes and rules; and, for certified HCCs, as applicable, evidence of timely claims payments and reports that substantiate compliance with all applicable statutes and rules regarding claims payment to physicians, health care providers, and patients;

(14) financial records: including statements; ledgers; checkbooks; inventory records; evidence of expenditures, investments, and debts; and related bank confirmations necessary to ascertain funding;

(15) compliance or accreditation: records regarding compliance with applicable statutes and rules or accreditation standards, including audits or examination reports by other entities, such as governmental authorities or accrediting agencies;

(16) satisfaction surveys: for certified HCCs only, patient, physician, and provider satisfaction surveys; and patient disenrollment and termination logs;

(17) reports: for certified HCCs only, any reports submitted by the HCC to a governmental entity; and

(18) other documents and information: any records requested pursuant to Insurance Code §848.153.

(b) The documents listed in this section must be maintained for at least five years from the anniversary date of the applicable document's creation.

Source Note: The provisions of this §13.415 adopted to be effective March 31, 2013, 38 TexReg 2100