MCQA Office Home
The MCQA Office is made up of knowledgeable staff members who provide assistance to injured employees, enrollees, certify and regulate HMO Carriers, certified WC Networks, Utilization Review Agents (URAs), Independent Review Organizations (IROs), industry representatives and other members of the public.
Health Maintenance Organization (HMO)
On the HMO homepage, you will be able to find a variety of important information, including a listing of HMOs, HMO licensing information, a link to HMO forms and other HMO-related information.
Workers' Compensation Networks (WCN)
The MCQA Office regulates Texas Workers' Compensation Networks which provide health care services to injured employees through certified health care networks. The office is responsible for the certification and regulation of the health care networks. In Texas, an employer may elect to use, but is not required to use, a certified workers' compensation network.
The Division of Workers' Compensation (DWC) oversees the state-regulated insurance program that pays medical bills and replaces some lost wages for employees who are injured at work or who have work-related diseases or illnesses.
Independent Review Organization (IRO)
Independent Review Organizations are independent third parties certified by the Texas Department of Insurance to review the utilization reviewer's decision that health care services are not medically necessary or appropriate or that health care services are experimental or investigational. If a health benefit plan or workers' compensation carrier refuses to pay for a treatment because it does not consider the treatment medically necessary or appropriate or because it considers the treatment to be experimental or investigational, you may be able to have an IRO review the decision.
Utilization Review Agent (URA)
Utilization Review Agents are registered or licensed entities that review requests for health care services being provided (concurrent), proposed to be provided (prospective) or already provided (retrospective). URAs determine whether services are medically necessary and appropriate and may also determine if services are experimental and investigational. The MCQA Office processes applications for entities seeking registration, licensure or licensure renewal as a URA within the state of Texas.
Exclusive Provider Benefit Plan (EPBP) and Preferred Provider Benefit Plan (PPBP) Networks
EPBP and PPBP networks are used by Texas Life/Health insurers to provide covered benefits to their EPBP and PPBP enrollees.
Registration of Provider Network Contracting Entities (PNCE)
Each person operating as a Provider Network Contracting Entity must register with The Texas Department of Insurance.
Third Party Administrator (TPA)
On the Third Party Administrator homepage, you will be able to find a variety of information, including a listing of TPAs, TPA licensing information, a link to TPA forms and other TPA-related information.
MCQA Office phone number: 512-676-6400 option 7(IROs and URAs) option 8 (HMO network adequacy and filings), 866-554-4926
MCQA Fax: 512-490-1013
- IRO Plan-Based Audit Memo
- HMO homepage
- HMO FAQs
- Prompt Payment of Clean Claims
- Network Adequacy (Waiver Requests)
For more information, contact:
Last updated: 09/04/2015