# 28 Tex. Admin. Code § 3.9206: 28 TAC § 3.9206. Quality Improvement and Utilization Management > Texas · Regulations · In force URL: https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9206 ## Section - **Citation:** 28 Tex. Admin. Code § 3.9206 - **Heading:** 28 TAC § 3.9206. Quality Improvement and Utilization Management - **Jurisdiction:** Texas - **Kind:** Regulations - **Status:** In force - **Text as of:** August 14, 2026 - **Source:** Compiled text - **Location:** Texas Administrative Code / Title 28 INSURANCE / Part 1 TEXAS DEPARTMENT OF INSURANCE / Chapter 3 LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES / 28 TAC § 3.9206 ## Text (a) An issuer must establish and maintain procedures to assure that the health care services provided to insureds are rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. These procedures must include: (1) mechanisms to assure availability, accessibility, quality, and continuity of care; (2) an ongoing internal quality improvement program to monitor and evaluate its health care services, including primary and specialist physician services, and ancillary and preventive health care services, in all institutional and non-institutional contexts; (3) a record of formal proceedings of quality improvement program activities and a means for maintaining documentation in a confidential manner. Quality improvement program minutes must be made available to the commissioner; (4) a physician review panel to assist in reviewing medical guidelines or criteria and to assist in determining the prescription drugs to be covered by the EPP, if the plan contains a prescription drug benefit; (5) an adequate patient record system that will facilitate documentation and retrieval of clinical information for the purpose of the issuer's evaluation of continuity and coordination of patient care and assessment of the quality of health care services provided to insureds; (6) a mechanism for making available to the commissioner the clinical records of insureds for examination and review. Such records are confidential and privileged, and are not subject to Government Code, Chapter 552, Public Information, or to subpoena, except to the extent necessary to enable the commissioner to enforce this title; and (7) a mechanism for the periodic reporting of quality improvement program activities to its governing body, providers, and appropriate organization staff. An issuer is also subject to the same quality improvement requirements as outlined in §11.1901 of this title (relating to Quality Improvement Structure). (b) An issuer must establish a mechanism for utilizing independent review organizations as outlined in Insurance Code Chapter 4201. ## Nearby sections - [28 Tex. Admin. Code § 3.9201 28 TAC § 3.9201. Application](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9201.md) - [28 Tex. Admin. Code § 3.9202 28 TAC § 3.9202. Definitions](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9202.md) - [28 Tex. Admin. Code § 3.9203 28 TAC § 3.9203. Policy and Premium Rates](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9203.md) - [28 Tex. Admin. Code § 3.9204 28 TAC § 3.9204. Contracting with Health Care Providers](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9204.md) - [28 Tex. Admin. Code § 3.9205 28 TAC § 3.9205. Compliance of Limited Provider Network](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9205.md) - [28 Tex. Admin. Code § 3.9206 28 TAC § 3.9206. Quality Improvement and Utilization Management](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9206.md) - [28 Tex. Admin. Code § 3.9207 28 TAC § 3.9207. Credentialing Requirements for Health Care Providers](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9207.md) - [28 Tex. Admin. Code § 3.9208 28 TAC § 3.9208. Provider Network: Accessibility and Availability](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9208.md) - [28 Tex. Admin. Code § 3.9209 28 TAC § 3.9209. Mandatory Disclosure Requirements](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9209.md) - [28 Tex. Admin. Code § 3.9210 28 TAC § 3.9210. Complaints System](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9210.md) - [28 Tex. Admin. Code § 3.9211 28 TAC § 3.9211. Filing of Complaints](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9211.md) - [28 Tex. Admin. Code § 3.9212 28 TAC § 3.9212. Appeal of Non-Medicaid Adverse Determinations](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9212.md) --- Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C3_S3_9206. Check the current official text before relying on it. Not legal advice.