28 Tex. Admin. Code § 10.22 - Contents of Application
Each certificate application must include:
(1) a description or a copy of the
applicant's basic organizational structure documents and other related
documents, including organizational charts or lists that show:
(A) the relationships and contracts between
the applicant and any affiliates of the applicant; and
(B) the internal organizational structure of
the applicant's management and administrative staff;
(2) a completed biographical affidavit, NAIC
UCAA Form 11 (Rev. 12/8/2020), from each person who governs or manages the
affairs of the applicant, including the members of the governing board of the
applicant, the chief executive officer, president, secretary, treasurer, chief
financial officer and controller, and any other individuals with substantially
similar responsibilities, provided that a biographical affidavit is not
required if a biographical affidavit from the person is already on file with
the department;
(3) a copy of the
form of any contract between the applicant and any provider or group of
providers as required under Insurance Code Chapter 1305, Subchapter D,
concerning Contracting Provisions, and §
10.41 and §
10.42 of this title (relating to
Network-Carrier Contracts and Network Contracts with Providers);
(4) a copy of any agreement with any third
party performing delegated functions on behalf of the applicant as required
under Insurance Code §
1305.154, concerning
Network-Carrier Contracts, and §
10.41 of this title (relating to
Network-Carrier Contracts);
(5) a
copy of the form of each contract with an insurance carrier, as described by
Insurance Code §
1305.154 and §
10.41 of this
title;
(6) each management contract
as described in §
10.40 of this title (relating to
Management Contracts), if applicable;
(7) a financial statement, current as of the
date of the application that includes the most recent calendar quarter,
prepared using generally accepted accounting principles, and including:
(A) a balance sheet that reflects a solvent
financial position;
(B) an income
statement;
(C) a cash flow
statement; and
(D) the sources and
uses of all funds;
(8) a
statement acknowledging that lawful process in a legal action or proceeding
against the network on a cause of action arising in this state is valid if
served in the manner provided by Insurance Code Chapter 804, concerning Service
of Process, for a domestic company;
(9) a description and a map of the
applicant's proposed service area or areas, with key and scale, that identifies
each county, ZIP code, partial ZIP code, or part of a county to be
served;
(10) a description of
programs and procedures to be utilized, including:
(A) a complaint system, as required under
Insurance Code Chapter 1305, Subchapter I, concerning Complaint Resolution, and
Chapter 10, Subchapter G, of this title (relating to Complaints);
(B) a quality improvement program, including
return-to-work and medical case management programs, as required under
Insurance Code Chapter 1305, Subchapter G, concerning Provision of Services by
Network; Quality Improvement Program, and §
10.81 of this title (relating to
Quality Improvement Program);
(C)
credentialing policies and procedures required under §
10.82 of this title (relating to
Credentialing);
(D) the utilization
review program described in Insurance Code Chapter 1305, Subchapter H,
concerning Utilization Review, and Chapter 10, Subchapter F, of this title
(relating to Utilization Review), if applicable; and
(E) criteria and procedures for employees to
select or change the employee's treating doctor, including procedures for
employees to select as the employee's treating doctor a doctor who the employee
selected, prior to injury, as the employee's HMO primary care physician or
provider;
(11) a
description of the network configuration that demonstrates the adequacy of the
network to provide comprehensive health care services sufficient to serve the
population of injured employees within the service area and maps that
demonstrate compliance with the access and availability standards under
Insurance Code Chapter 1305, Subchapter G, and §
10.80 of this title (relating to
Accessibility and Availability Requirements). This description must include, at
a minimum, the following:
(A) a map for each
specialty providing services to injured employees in accordance with §
10.80 of this title, each of which
must include:
(i) each location of health care
providers and facilities within the proposed service area, indicating each
location by symbols of the network's own choosing; and
(ii) the distance from any point in the
network's designated service area to each location;
(B) names; addresses, including ZIP codes;
specialty or specialties; board certifications, if any; professional license
numbers; and hospital affiliations of network providers, including treating
doctors, in sufficient number and specialty to provide all required health care
services in a timely, effective, and convenient manner;
(C) names; addresses; federal employer
identification number (FEIN); licenses; and types of health care facilities,
including hospitals, rehabilitation facilities, diagnostic and testing
facilities, ambulatory surgical centers, and interdisciplinary pain
rehabilitation programs or interdisciplinary pain rehabilitation treatment
facilities. The network must also demonstrate adequate access to emergency
care;
(D) information indicating
whether each network provider is accepting new patients from the workers'
compensation health care network;
(E) information indicating which network
doctors are trained and certified to perform maximum medical improvement
determinations and impairment rating services;
(F) information identifying which network
providers provide telehealth service, telemedicine medical service, or
teledentistry dental service, indicating which of these providers will provide
telehealth service, telemedicine medical service, or teledentistry dental
service only; and
(12) the
physical location of the applicant's books and records, including:
(A) financial and accounting
records;
(B) investment
records;
(C) organizational
documents of the applicant; and
(D)
minutes of all meetings of the applicant's governing board and executive or
management committees;
(13) a business plan that describes the
applicant's intended operations in this state, including both a narrative
description and projections related to anticipated revenue and profitability
for the first two years of operation after certification;
(14) a completed financial authorization form
sufficient to allow the department to confirm directly with appropriate
financial institutions the reported assets of the applicant, unless the entity
is already licensed by the department;
(15) the applicant's plan for provision of
care to injured employees who live temporarily outside the service area, if
applicable;
(16) the applicant's
plan for provision of maximum medical improvement determinations and impairment
rating services, including verification that the network doctors reported under
paragraph (11)(E) of this section have completed the training and testing
required under Labor Code §
408.023, concerning List
of Approved Doctors; Duties of Treating Doctors, and rules adopted by the
Commissioner of Workers' Compensation;
(17) the applicant's plan for obtaining
certification by doctors and health care practitioners of filing the required
financial disclosure with the Division of Workers' Compensation under Labor
Code §
408.023 and §
413.041, concerning
Disclosure;
(18) the form of the
notice of network requirements and employee information, and the acknowledgment
form required under Insurance Code §
1305.005, concerning
Participation in Network; Notice of Network Requirements, and §
10.60 of this title (relating to
Notice of Network Requirements; Employee Information);
(19) the applicant's plan for monitoring
whether providers have been provided and are following treatment guidelines,
return-to-work guidelines, and individual treatment protocols as required under
Insurance Code §
1305.304, concerning
Guidelines and Protocols, and §
10.83 of this title (relating to
Guidelines and Protocols);
(20) a
description of treatment guidelines and return-to-work guidelines, and the
network medical director's certification that the guidelines are
evidence-based, scientifically valid, and outcome-focused, and be designed to
reduce inappropriate or unnecessary health care while safeguarding necessary
care, as required under Insurance Code §
1305.304 and §
10.83(a) of this
title; and
(21) a certification
that:
(A) the network's medical director is
an occupational medicine specialist; or
(B) the network employs or contracts with an
occupational medicine specialist.
Notes
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