28 TAC §21.3201 .
The Texas Department of Insurance proposes amendments to §21.3201 concerning the Texas Standardized Credential Application for physicians, advanced practice nurses and physician assistants. These amendments are necessary to implement Insurance Code Article 21.58D, as amended by Acts 2003, 78th Legislature in §11 of House Bill (HB) 1095. Since September 1, 2001 , Article 21.58D has required public or private hospitals, health maintenance organizations (HMOs) and preferred provider organizations to use standardized forms developed by the department for the verification of credentials of a physician. Article 21.58D was amended to include advanced practice nurses and physician assistants in the group of professionals whose credentials must be verified, using a standardized form prescribed by the Department of Insurance (department), by public or private hospitals, HMOs and preferred provider organizations. To effect this implementation, this proposed amendment adds definitions for "advanced practice nurse" and "physician assistant" to §21.3201. References to "advanced practice nurse" and "physician assistant" are included where appropriate to make clear that the department´s standardized form must be used to verify their credentials, and an effective date is specified.
Additionally, minor clarification changes are proposed. These include appropriate renumbering of subsections and paragraphs, and updating a reference to the chapter of the Insurance Code that addresses requirements for HMOs. The language in §21.3201(a) indicating that the department´s form is incorporated by reference and the description of the form that appeared at §21.3201(c)(2) are unnecessary and this proposal deletes them.
Kim Stokes, Senior Associate Commissioner, Life, Health and Licensing Program, has determined that for each year of the first five years the proposed amendments will be in effect, there will be no fiscal impact to state and local governments as a result of the enforcement or administration of the rule. There will be no measurable effect on local employment or the local economy as a result of the proposal.
Ms. Stokes has also determined that for each year of the first five years the sections are in effect, the public benefits anticipated as a result of the proposed sections will be the efficiencies that result from the use of simplified standard credentialing forms and increased public confidence in services rendered by advanced practice nurses and physician assistants with whom hospitals, HMOs and preferred provider organizations contract. There will be some minor economic cost to persons required to comply with the amended rule. Advanced practice nurses and physician assistants will incur the costs associated with downloading and completing the credentialing form. However, this cost is a direct result of the enactment of HB 1095, and therefore not caused by the adoption of this rule amendment.
The department believes there will be no adverse effect on small and micro businesses. However, if there is an adverse impact, it would be the direct result of the enactment of HB 1095, and therefore not caused by the adoption of these rule amendments. Waiver or modification of the proposed amendments for small or micro businesses is not appropriate, because it would establish disparate standards for large and small businesses that are required to comply with these statutory requirements, and could thwart the purpose of the statute.
To be considered, written comments on the proposal must be submitted no later than 5:00 p.m. on December 13, 2004 to Gene C. Jarmon, General Counsel and Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P. O. Box 149104, Austin, Texas 78714-9104. An additional copy of the comment must be simultaneously submitted to Bill Bingham, Deputy for Regulatory Matters, Life, Health and Licensing Program, Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. A request for a public hearing should be submitted separately to the Office of the Chief Clerk.
The amendments are proposed under the Insurance Code Articles 20A.39 and 21.58D, and §36.001. Article 20A.39 provides the statutory basis for credentialing of physicians and providers, and Article 21.58D requires hospitals, HMOs and preferred provider organizations to use forms prescribed by the department when verifying the credentials of physicians, advanced practice nurses and physician assistants. Section 36.001 provides that the Commissioner of Insurance may adopt any rules necessary and appropriate to implement the powers and duties of the Texas Department of Insurance under the Insurance Code and other laws of this state.
The following sections are affected by this proposal: Insurance Code Articles 20A.39 and 21.58D, and §36.001
§21.3201. Texas Standardized Credentialing Application for Physicians, Advanced Practice Nurses and Physician Assistants.
(a) Purpose and Applicability. The purpose of this section is to identify the [adopt a] standardized credentialing application form [as] required by the Insurance Code Article 21.58D. Hospitals, health maintenance organizations, preferred provider benefit plans, and preferred provider organizations are required to use this form for credentialing and recredentialing of physicians , advanced practice nurses and physician assistants.
(b) Definitions. The following words and terms when used in this section shall have the following meanings:
(1) Advanced practice nurse--An advanced practice nurse as that term is defined by Occupations Code §301.152.
(2) [(1)] Credentialing--The process of collecting, assessing, and validating qualifications and other relevant information pertaining to a physician or provider to determine eligibility to deliver health care services.
(3) [(2)] Department--Texas Department of Insurance.
(4) [ (3) ] Health maintenance organization--A health maintenance organization as that term is defined by the Insurance Code §843.002(14) [ Article 20A.02(n) ].
(5) [ (4) ] Hospital--A licensed public or private institution as defined by Chapter 241, Health and Safety Code, and any hospital owned or operated by state government.
(6) [ (5) ] Physician--An individual licensed to practice medicine in this state.
(7) Physician assistant--A person who holds a license issued under Chapter 204, Occupations Code.
(8) [ (6) ] Preferred provider benefit plan--A plan issued by an insurer under the Insurance Code Article 3.70-3C.
(9) [ (7) ] Preferred provider organization--An organization contracting with an insurer issuing a preferred provider benefit plan under the Insurance Code Article 3.70-3C, for the purpose of providing a network of preferred providers.
(10) [ (8) ] Recredentialing--The periodic process by which:
(A) qualifications of physicians, advanced practice nurses and physician assistants are reassessed;
(B) performance indicators including utilization and quality indicators are evaluated; and
(C) continued eligibility to provide services is determined.
(c) Texas Standardized Credentialing Application.
[ (1) ] The [ Department adopts and incorporates by reference the ] Texas Standardized Credentialing Application shall be used [ for required use ] by all hospitals, health maintenance organizations, preferred provider benefit plan insurers, and preferred provider organizations for credentialing and recredentialing of physicians , advanced practice nurses and physician assistants.
[ (2) The application consists of three sections. Section I requests personal, professional, and educational information. Section II consists of disclosure questions on sanctions, professional liability insurance, malpractice claims history, criminal/civil history, and ability to perform job. Section III consists of an Authorization, Acknowledgment, Attestation, and Release form. ]
(d) Effective date. The application form is required for initial credentialing or recredentialing that occurs on or after August 1, 2002 for physicians. The application form is required for advanced practice nurses and physician assistants for initial credentialing and recredentialing that occurs on or after September 1, 2003.
(e) Availability. This form may be obtained on the Department's Web site at www.tdi.state.tx.us or from the Texas Department of Insurance, Quality Assurance Section, HMO Division, Mail Code 103-6A, P. O. Box 149104, Austin, Texas, 78714-9104; or by calling 800-599-SHOP (1476); in Austin, 305-7211. Reproduction of this form without any changes is allowed.
(f) (No Change.)