Section 12.103 - Information Required in Original Application for Certificate of RegistrationThe IRO application form requires information that is necessary for the commissioner to determine whether an applicant is qualified for a certificate of registration as an IRO under Insurance Code § 4202.004, including:
(1) a summary of the independent review plan that meets the requirements of § 12.201 of this chapter, which must include: (A) a summary description of review criteria and review procedures to be used to determine medical necessity or appropriateness of health care;(B) a summary description of review criteria and review procedures to be used to determine the experimental or investigational nature of health care;(C) a certification signed by the IRO's medical director that the review criteria and review procedures to be applied in review determinations are established with input from appropriate health care providers and approved by physicians under § 12.201(3) of this chapter;(D) procedures ensuring that the information regarding the reviewing physicians and providers is updated under § 12.111(a) of this chapter to ensure the independence of each health care provider or physician making review determinations; and(E) a summary description of criteria and review procedures to be used by the medical director to conduct quality assurance audits under § 12.202(c)(2) of this chapter.(2) copies of policies and procedures that ensure that all applicable state and federal laws to protect the confidentiality of medical records and personal information are followed. These procedures must comply with § 12.208 of this chapter;(3) a certification, signed by an officer, director, or owner of the IRO, that the IRO and any party that performs an IRO function through contracts and subcontracts will comply with Insurance Code Chapter 4202 and this chapter. The certification must include a statement that the IRO is responsible for ensuring that all contracted and subcontracted functions are performed according to Insurance Code Chapter 4202 and this chapter, subject to the IRO's oversight and monitoring, and that the IRO retains ultimate responsibility for compliance;(4) a description of personnel and their credentials and a completed profile for each physician and provider, as described in § 12.202 of this chapter that must include: (A) the credentialing and recredentialing procedures used by the IRO applicant to verify physician and provider credentials and the computer processes, electronic databases, and records, if any, used to make the verification; and(B) the credentialing software used by the applicant for managing the processes, databases, and records described in subparagraph (A) of this paragraph;(5) a description of hours of operation and how the IRO may be contacted after hours and during weekends and holidays, as set out in § 12.207 of this chapter;(6) a description of the applicant's use of communications, records, and computer processes to manage the independent review process;(7) a description and evidence of accreditation from a nationally recognized accrediting organization, if any, that imposes requirements for accreditation that are the same as, substantially similar to, or more stringent than the department's requirements for a certificate of registration. Evidence of accreditation will be maintained in the department's file for the IRO applicant, and the applicant may request expedited approval of the certificate of registration with evidence of accreditation from a nationally recognized accrediting organization;(8) the organizational information, documents, and all amendments that must include: (A) written evidence that the applicant is incorporated in this state, which may include a copy of the Certificate of Formation from the Texas Secretary of State;(B) for an applicant that is publicly held, the name, address, and Federal Employer Identification Number (EIN) of each stockholder or owner of more than 5 percent of any stock or options;(C) a chart showing the internal organizational structure of the applicant's management and administrative staff;(D) a chart showing contractual arrangements of the applicant, including all contracts between the applicant and any person and all subcontracts with other persons to perform any business or daily functions of an IRO; and(E) copies of the contract and subcontract with any person who will perform IRO functions on behalf of the applicant. All contracts and subcontracts must include at a minimum: (i) a provision that the contracted or subcontracted party will comply with § 12.208 of this chapter;(ii) a provision that the applicant is responsible for ensuring that all contracted and subcontracted functions are performed under Insurance Code Chapter 4202 and this chapter, subject to the applicant's oversight and monitoring;(iii) a provision that the applicant retains ultimate responsibility for compliance; and(iv) a provision that, on request, the contracted party will provide the applicant with data necessary for the applicant to comply with department requests for information about IRO functions;(9) the name of any holder of bonds or notes of the applicant that exceed $100,000;(10) the name, address, EIN, and type of business of each corporation or other organization that the applicant controls or is affiliated with and the nature and extent of the affiliation or control, and a chart or list clearly identifying the relationships between the applicant and any affiliates;(11) biographical information about officers, directors, and executives, including information requested in the biographical affidavit as required in § 12.102(b) of this chapter:(A) the applicant must submit a complete set of fingerprints for each director, officer, and executive of the applicant and for each owner or shareholder of the applicant, or if the applicant is publicly held, each owner or shareholder of more than 5 percent of any of the applicant's stock or options as described by Insurance Code § 4202.004(a)(1), in compliance with § 1.503 and § 1.504 of this title;(B) the applicant must submit the name and biographical information for each director, officer, and executive of the applicant and of any entity listed under paragraph (10) of this section and a description of any relationship the named individual has that represents revenue equal to or greater than 5 percent of that individual's total annual revenue or which represents a holding or investment worth $100,000 or more in any of the following entities: (i) a health benefit plan;(ii) a health maintenance organization;(iv) a utilization review agent;(v) a nonprofit health corporation;(vii) a health care provider;(ix) a group representing any of the entities described by clauses (i) - (viii) of this subparagraph.(C) the applicant must identify any relationship between the applicant and any affiliate or other organization in which an officer, director, or employee of the applicant holds a 5 percent or more interest;(D) the applicant must submit a list of any currently outstanding loans or contracts to provide services between the applicant, affiliates, or any other person relating to any functions performed by or on behalf of the applicant;(12) documentation from the comptroller demonstrating the applicant's good standing and right to transact business in this state;(13) for an application for a certificate of registration or renewal of a certificate of registration as an IRO in this state made on or after July 7, 2015, a sworn statement from an officer of the organization that: (A) the applicant's primary office included on the IRO application form is located and maintained at a physical address in this state. As a condition of holding a certificate of registration to conduct the business of independent review in this state, an IRO must locate and maintain its primary office at a physical address in this state;(B) the primary office is equipped with a computer system capable of: (i) processing requests for independent review; and(ii) accessing all electronic records related to the review and the independent review process;(C) all records are maintained electronically and will be made available to the department on request;(D) in the case of an office located in a residence, the working office must be located in a room set aside for independent review business purposes and in a manner to ensure confidentiality; and(E) medical records are maintained according to § 12.208 of this chapter;(14) the percentage of the applicant's revenues that are anticipated to be derived from independent reviews conducted; and(15) a disclosure of any enforcement actions related to the provision of medical care or conducting of medical reviews taken against a person subject to the fingerprint requirements under § 1.503 and § 1.504 of this title.28 Tex. Admin. Code § 12.103
The provisions of this §12.103 adopted to be effective November 26, 1997, 22 TexReg 11363; amended to be effective December 26, 2010, 35 TexReg 11281; Amended by Texas Register, Volume 40, Number 19, May 8, 2015, TexReg 2561, eff. 7/7/2015