(a) The department has authority to conduct examinations of HMOs under Insurance Code Chapters 401 (concerning Audits and Examinations) and 751 (concerning Market Conduct Surveillance), and Insurance Code §843.156 (concerning Examinations) and §843.251 (concerning Complaint System Required; Commissioner Rules and Examination), and such examinations are subject to §7.83 of this title (relating to Appeal of Examination Reports). The department will conduct examinations to determine the financial condition (financial exams), quality of health care services (quality of care exams), or compliance with laws affecting the conduct of business (market conduct exams).     
      (b) The following documents must be available for review at the HMO's office located within Texas or at a location approved by the department under Insurance Code §803.003 (concerning Authority to Locate Out of State):      
        (1) administrative: policy and procedure manuals; physician and provider manuals; enrollee materials; organizational charts; key personnel information, for example, resumes and job descriptions; and other items as requested;       
        (2) quality improvement: program description, work plans, program evaluations, and committee and subcommittee meeting minutes;       
        (3) utilization management: program description, policies and procedures, criteria used to determine medical necessity, and templates of adverse determination letters; adverse determination logs, including all levels of appeal; and utilization management files;       
        (4) complaints and appeals: policies and procedures and templates of letters; complaint and appeal logs, including documentation and details of actions taken; and complaint and appeal files;       
        (5) satisfaction surveys: enrollee, physician, and provider satisfaction surveys, and enrollee disenrollment and termination logs;       
        (6) health information systems: policies and procedures for accessing enrollee health records and a plan to provide for confidentiality of those records;       
        (7) network configuration information: as required by §11.204(19) of this title (relating to Contents) demonstrating adequacy of the physician, dentist, and provider network;       
        (8) executed agreements, including:                  (A) management services agreements;                   (B) administrative services agreements; and                   (C) delegation agreements;         
        (9) executed physician and provider contracts: copy of the first page, including form number, and signature page;       
        (10) executed subcontracts: copy of the first page, including the form number, and signature page of all contracts with subcontracting physicians and providers;       
        (11) credentialing: credentialing policies and procedures and credentialing files;       
        (12) reports: any reports submitted by the HMO to a governmental entity;       
        (13) claims systems: policies and procedures and systems or processes that demonstrate timely claims payments, and reports that substantiate compliance with all applicable statutes and rules regarding claims payment to physicians, providers, and enrollees;       
        (14) financial records: financial information, including statements, ledgers, checkbooks, inventory records, evidence of expenditures, investments and debts; and       
        (15) other: any other records requested by the department to demonstrate compliance with applicable statutes and rules.       
      (c) The department will conduct quality of care exams as follows:      
        (1) Entrance conference. The examination team or assigned examiner may hold an entrance conference with the HMO's key management staff or their designee before beginning the examination.       
        (2) Interviews. Examination team members or the examiner may conduct interviews with key management staff or their designated personnel.       
        (3) Exit conference. On completion of the examination, the examination team or examiner may hold an exit conference with the HMO's key management staff or their designee.       
        (4) Written report of examination. The examination team or examiner will prepare a written report of the examination. The department will provide the HMO with the written report, and if any significant deficiencies are cited, the department will issue a letter outlining the time frames for a corrective action plan and corrective actions.       
        (5) Corrective action plan. If the examination team or examiner cites significant deficiencies, the HMO must provide a signed corrective action plan to the department no later than 30 days from receipt of the written examination report. The HMO's plan must provide for correction of these deficiencies no later than 90 days from the receipt of the written examination report.       
        (6) Verification of correction. The department will verify the correction of deficiencies by submitted documentation or by on-site examination.       
     Source Note:        The provisions of this §11.303 adopted to be effective August 1, 2017, 42 TexReg 2169; amended to be effective March 30, 2021, 46 TexReg 2036