| (a) The following documents must be made available
for review at the applicant's office in Texas or another location
within Texas agreed to by the department and on request during the
application process:
(1) administrative: policy and procedure manuals;
(2) health information systems: policies and procedures
for accessing enrollee health records and a plan to provide for confidentiality
of those records complying with applicable law;
(3) executed agreements, including:
(A) management services agreements;
(B) administrative services agreements; and
(C) delegation agreements;
(4) executed physician and provider contracts: a copy
of the first page, including the form number, and signature page;
(5) executed subcontracts: a copy of the first page,
including the form number, and signature page of all contracts with
subcontracting physicians and providers;
(6) manuals: current physician manual and current provider
manual provided to each contracting physician or provider, which must
contain details of the provisions that govern the physicians and providers;
(7) credentialing files: as specified in §11.1902(4)
of this title (relating to Quality Improvement Program for Basic,
Single Service, and Limited Service HMOs);
(8) reporting system: the statistical reporting system
developed and maintained by the applicant that allows for compiling,
developing, evaluating, and reporting statistics relating to the cost
of operation, the pattern of utilization of services, and the accessibility
and availability of services;
(9) claims systems: policies and procedures that demonstrate
the capacity to pay claims timely and to comply with all applicable
statutes and rules;
(10) financial records: financial information, including
statements, ledgers, checkbooks, inventory records, evidence of expenditures,
investments, and debts; and
(11) any other records: demonstrating compliance with
applicable statutes and rules, including audits or examination reports
by other entities, including governmental authorities or accrediting
agencies.
(b) After approval of the application, the following
documents may be maintained outside Texas if the HMO has received
prior approval by the commissioner in compliance with Insurance Code §803.003
(concerning Authority to Locate Out of State):
(1) the financial records listed in subsection (a)(10)
of this section;
(2) minutes of HMO organizational meetings, which indicate
the type and date of each meeting and the officer or officers who
are responsible for the handling of the funds of the applicant;
(3) minutes of meetings of the HMO board of directors;
and
(4) management committee meeting minutes.
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