SECTION 3.9206. Quality Improvement and Utilization Management

(a) An issuer must establish and maintain procedures to assure that the health care services provided to insureds are rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. These procedures must include:

(1) mechanisms to assure availability, accessibility, quality, and continuity of care;

(2) an ongoing internal quality improvement program to monitor and evaluate its health care services, including primary and specialist physician services, and ancillary and preventive health care services, in all institutional and non-institutional contexts;

(3) a record of formal proceedings of quality improvement program activities and a means for maintaining documentation in a confidential manner. Quality improvement program minutes must be made available to the commissioner;

(4) a physician review panel to assist in reviewing medical guidelines or criteria and to assist in determining the prescription drugs to be covered by the EPP, if the plan contains a prescription drug benefit;

(5) an adequate patient record system that will facilitate documentation and retrieval of clinical information for the purpose of the issuer's evaluation of continuity and coordination of patient care and assessment of the quality of health care services provided to insureds;

(6) a mechanism for making available to the commissioner the clinical records of insureds for examination and review. Such records are confidential and privileged, and are not subject to Government Code, Chapter 552, Public Information, or to subpoena, except to the extent necessary to enable the commissioner to enforce this title; and

(7) a mechanism for the periodic reporting of quality improvement program activities to its governing body, providers, and appropriate organization staff. An issuer is also subject to the same quality improvement requirements as outlined in §11.1901 of this title (relating to Quality Improvement Structure).

(b) An issuer must establish a mechanism for utilizing independent review organizations as outlined in Insurance Code Chapter 4201.

Source Note: The provisions of this §3.9206 adopted to be effective September 17, 2003, 28 TexReg 7993; amended to be effective May 11, 2022, 47 TexReg 2758