Texas § IN.1301.0051 - EXCLUSIVE PROVIDER BENEFIT PLANS

§ IN.1301.0051. EXCLUSIVE PROVIDER BENEFIT PLANS

EXCLUSIVE PROVIDER BENEFIT PLANS: QUALITY IMPROVEMENT AND UTILIZATION MANAGEMENT. (a) An insurer that offers an exclusive provider benefit plan shall establish procedures to ensure that health care services are provided to insureds under reasonable standards of quality of care that are consistent with prevailing professionally recognized standards of care or practice. The procedures must include: (1) mechanisms to ensure availability, accessibility, quality, and continuity of care; (2) subject to Section 1301.059 , a continuing quality improvement program to monitor and evaluate services provided under the plan, including primary and specialist physician services and ancillary and preventive health care services, provided in institutional or noninstitutional settings; (3) a method of recording formal proceedings of quality improvement program activities and maintaining quality improvement program documentation in a confidential manner; (4) subject to Section 1301.059 , a physician review panel to assist the insurer in reviewing medical guidelines or criteria; (5) a patient record system that facilitates documentation and retrieval of clinical information for the insurer's evaluation of continuity and coordination of services and assessment of the quality of services provided to insureds under the plan; (6) a mechanism for making available to the commissioner the clinical records of insureds for examination and review by the commissioner on request of the commissioner; and (7) a specific procedure for the periodic reporting of quality improvement program activities to: (A) the governing body and appropriate staff of the insurer; and (B) physicians and health care providers that provide health care services under the plan. (b) Minutes of a formal proceeding of the quality improvement program established under Subsection (a) shall be made available to the commissioner on request of the commissioner. (c) Insured records made available to the commissioner under Subsection (a)(6) are confidential and privileged, and are not subject to Chapter 552 , Government Code, or to subpoena, except to the extent necessary for the commissioner to enforce this chapter. Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772 ), Sec. 9, eff. September 1, 2011.