Tex.
Ins. Code Section 843.156
Examinations
(a)
The commissioner may examine the quality of health care services and the affairs of any health maintenance organization or applicant for a certificate of authority under this chapter. The commissioner may conduct an examination as often as the commissioner considers necessary, but shall conduct an examination at least once every three years.(b)
A health maintenance organization shall make its books and records relating to its operations available for an examination and shall facilitate an examination in every way.(c)
Each physician and provider with whom the health maintenance organization has a contract, agreement, or other arrangement is required to make available for an examination only that portion of the physician’s or provider’s books and records that is relevant to the physician’s or provider’s relationship with the health maintenance organization.(d)
On request of the commissioner, a health maintenance organization shall provide to the commissioner a copy of any contract, agreement, or other arrangement between the health maintenance organization and a physician or provider. Documentation provided to the commissioner under this subsection is confidential and is not subject to the public information law, Chapter 552 (Public Information), Government Code.(e)
Medical, hospital, and health records of enrollees and records of physicians and providers providing service under an independent contract with a health maintenance organization are subject to an examination only as necessary for a continuing quality of health assurance program concerning health care procedures and outcomes that is established in accordance with an approved plan under this chapter. The plan shall provide for adequate protection of the confidentiality of medical information. Medical information may be disclosed only in accordance with this chapter and other applicable law and is subject to subpoena only on a showing of good cause.(f)
The commissioner may examine and use the records of a health maintenance organization, including records of a quality of care assurance program and records of a medical peer review committee, as necessary to implement the purposes of this chapter, Section 1367.053 (Coverage Required), Subchapter A (Applicability of Certain Definitions), Chapter 1452 (Physician and Provider Credentials), Subchapter B, Chapter 1507 (Consumer Choice of Benefits Plans), Chapters 222 (Life, Health, and Accident Insurance Premium Tax), 251 (General Provisions), and 258 (Health Maintenance Organizations), as applicable to a health maintenance organization, and Chapters 1271 (Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges) and 1272 (Delegation of Certain Functions by Health Maintenance Organization), including commencement of an enforcement action under Section 843.461 (Enforcement Actions) or 843.462 (Operations During Suspension or After Revocation of Certificate of Authority). Information obtained under this subsection is confidential and privileged and is not subject to the public information law, Chapter 552 (Public Information), Government Code, or to subpoena except as necessary for the commissioner to enforce this chapter, Section 1367.053 (Coverage Required), Subchapter A (Applicability of Certain Definitions), Chapter 1452 (Physician and Provider Credentials), Subchapter B, Chapter 1507 (Consumer Choice of Benefits Plans), Chapter 222 (Life, Health, and Accident Insurance Premium Tax), 251 (General Provisions), or 258 (Health Maintenance Organizations), as applicable to a health maintenance organization, or Chapter 1271 (Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges) or 1272 (Delegation of Certain Functions by Health Maintenance Organization). In this subsection, “medical peer review committee” has the meaning assigned by Section 151.002 (Definitions), Occupations Code.(g)
For the purpose of an examination, the commissioner may administer oaths to and examine the officers and agents of a health maintenance organization and the principals of physicians and providers described by this section concerning their business.(h)
Chapter 86 (Revocation or Modification of Certificate of Authority; Authority to Bring Certain Actions), Section 401.101 (Use of Department Examiner or Other Qualified Person or Firm), and Subchapters B (Duty to Examine Carriers) and D, Chapter 401 (Audits and Examinations), apply to a health maintenance organization, except to the extent that the commissioner determines that the nature of the examination of a health maintenance organization renders the applicability of those provisions clearly inappropriate.(i)
Section 38.001 (Inquiries), Section 81.003 (Notification of Certain Disciplinary Actions Occurring in Other States; Civil Penalty), and Chapter 82 (Sanctions) apply to a health maintenance organization.
Source:
Section 843.156 — Examinations, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.843.htm#843.156 (accessed Jun. 5, 2024).
