The department has authority to conduct onsite examinations of HMOs under TIC §843.251 and TIC §843.156 and 28 TAC §11.303. After the Initial exam, examinations will be on a triennial basis, although the department reserves the right to perform a complaint or target exam.
The Department may also perform a desk review or an onsite review. We will request documentation that needs to be reviewed for an examination prior to our review.
The network must make available to the department all records relating to the HMO's operations. The department will examine the following functions of the HMO:
- Credentialing policies and procedures and file review
- HMO operations
- Claims review
- Quality improvement
- Complaint policies and procedures and file review
- Network availability and accessibility
- Delegated Entity and the Oversight of Delegated Entity
- Single service – as applicable
- Utilization management – file review only