SECTION 7.1611. Operational Review and On-Site Audit

(a) No less than two times each fiscal year, an insurer shall review the operations of each of its administrators that, in the aggregate, administers benefits in Texas on behalf of the insurer for more than 100 certificate holders, injured employees, plan participants, or policyholders. A review may be conducted on the premises of the insurer or at another location designated by the insurer and may be conducted by electronic means.

(b) No less than once every two fiscal years, an insurer shall conduct an on-site audit of each of its administrators that, in the aggregate, administers benefits in Texas on behalf of the insurer for more than 100 certificate holders, injured employees, plan participants, or policyholders.

(c) Notwithstanding subsection (a) of this section, an insurer is not required to review the operations of an administrator under subsection (a) of this section more than one time in the same fiscal year in which the insurer conducts an on-site audit of that administrator pursuant to subsection (b) of this section.

(d) Both a review and on-site audit required under subsections (a) and (b) of this section must:

(1) assess the business practices and procedures of the administrator to ensure competent administration, including evaluating:

(A) the administrator's compliance with the Insurance Code, the Labor Code, and any rules adopted thereunder, as applicable;

(B) the administrator's compliance with the provisions of the written agreement with the insurer;

(C) the administrator's performance of claims adjudication and payment;

(D) the adequacy of the financial security maintained by the administrator, if any; and

(E) the administrator's practices and procedures for establishing the adequacy of the insurer's reserves, if any; and

(2) include a written summary of the objectives and scope of the review or on-site audit and the results of the review or on-site audit, including a corrective action plan addressing any deficiencies found during the review or on-site audit.

(e) The purpose of the on-site audit required by subsection (b) of this section is to verify the accuracy, integrity, and completeness of the information received during a review conducted by the insurer pursuant to subsection (a) of this section. In addition to the requirements of subsection (d) of this section, an on-site audit conducted by an insurer pursuant to subsection (b) of this section must also:

(1) include a physical inspection of the administrator's place of business; and

(2) include a written assessment of the reliability of the information provided to the insurer and relied upon by the insurer when conducting a review or on-site audit of the administrator under this section.

(f) A review or on-site audit required under this section may be performed by an insurer or the insurer's designated representative.

(g) An insurer may meet the requirements of this section for an administrator subcontractor by reviewing and auditing the administrator contractor only, provided that:

(1) the information supplied to the insurer by the administrator contractor includes all necessary and relevant information relating to the administrator subcontractor; and

(2) no evidence of material non-compliance by the administrator subcontractor exists.

(h) All information and documentation related to a review or on-site audit shall be made available to the commissioner upon request and must remain on file with the insurer for at least five years from the date of the review or on-site audit.

Source Note: The provisions of this §7.1611 adopted to be effective June 25, 2009, 34 TexReg 4143