28 Tex. Admin. Code § 11.1902 - Quality Improvement Program for Basic, Single Service, and Limited Service HMOs
The QI program for basic, single service, and limited service HMOs must be continuous and comprehensive, addressing both the quality of clinical care and the quality of services. The HMO must dedicate adequate resources, such as personnel and information systems, to the QI program.
(1) Written description. The QI program must
include a written description of the QI program that outlines program
organizational structure, functional responsibilities, and meeting
frequency.
(2) Work plan. The QI
program must include an annual QI work plan designed to reflect the type of
services and the population served by the HMO in terms of age groups, disease
categories, and special risk status. The work plan must:
(A) include objective and measurable goals,
planned activities to accomplish the goals, time frames for implementation,
responsible individuals, and evaluation methodology; and
(B) address each program area, including:
(i) network adequacy, which includes
availability and accessibility of care, including assessment of open and closed
physician and individual provider panels;
(ii) continuity of health care and related
services;
(iii) clinical
studies;
(iv) the adoption and
periodic updating of clinical practice guidelines or clinical care standards,
which the QI program must ensure:
(I) are
approved by participating physicians and individual providers;
(II) are communicated to physicians and
individual providers; and
(III)
include preventive health services;
(v) enrollee, physician, and individual
provider satisfaction;
(vi) the
complaint and appeals process, complaint data, and identification and removal
of communication barriers that may impede enrollees, physicians, and providers
from effectively making complaints against the HMO;
(vii) preventive health care through health
promotion and outreach activities;
(viii) claims payment processes;
(ix) contract monitoring, including
delegation oversight and compliance with filing requirements;
(x) utilization review processes;
(xi) credentialing;
(xii) member services; and
(xiii) pharmacy services, including drug
utilization.
(3) Evaluation. The QI program must include
an annual written report on the QI program, which includes completed
activities, trending of clinical and service goals, analysis of program
performance, and conclusions.
(4)
Credentialing. An HMO must implement a documented process for selection and
retention of contracted physicians and providers. The credentialing process
must comply with NCQA or American Accreditation HealthCare Commission, Inc.,
standards, to the extent that those standards do not conflict with the laws of
this state. An HMO must have a documented process for expedited credentialing
of physicians, podiatrists, and therapeutic optometrists, including a
documented process for payment of claims during the expedited credentialing
process, in compliance with Insurance Code Chapter 1452 (concerning Physician
and Provider Credentials).
(5) Site
visits for cause.
(A) The HMO must have
procedures for detecting deficiencies after a site visit. When the HMO
identifies new deficiencies, the HMO must reevaluate the site and institute
actions for improvement.
(B) An HMO
may conduct a site visit to the office of any physician or provider at any time
for cause. The HMO may conduct the site visit to evaluate a complaint or other
precipitating event, which may include an evaluation of any facilities or
services related to a complaint or event and an evaluation of medical records,
equipment, space, accessibility, appointment availability, or confidentiality
practices, as appropriate.
(6) Peer Review. The QI program must provide
for a peer review procedure for physicians and individual providers, as
required by the Medical Practice Act, Occupations Code, Chapter 151, Subchapter
A, (concerning General Provisions). The HMO must designate a credentialing
committee that uses a peer review process to make recommendations regarding
credentialing decisions.
(7)
Delegation of Credentialing. If the HMO delegates credentialing functions to
other entities, its credentialing process must comply with the standards
promulgated by the NCQA, to the extent that those standards do not conflict
with other laws of this state.
Notes
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