88R22032 CJD-D
 
  By: Cortez H.B. No. 4367
 
  Substitute the following for H.B. No. 4367:
 
  By:  Oliverson C.S.H.B. No. 4367
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the preauthorization of medical or health care services
  by a health maintenance organization or an insurer.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 843.348, Insurance Code, is amended by
  amending Subsection (g) and adding Subsection (g-1) to read as
  follows:
         (g)  Unless a physician or provider has materially
  misrepresented the proposed health care services or has
  substantially failed to perform the proposed health care services,
  if [If] the health maintenance organization has preauthorized
  health care services, the health maintenance organization may not
  deny or reduce payment to the physician or provider for those
  services based on:
               (1)  medical necessity or appropriateness of care; or
               (2)  eligibility or coverage determinations if the
  proposed health care service is provided to the enrollee before the
  31st day after the date the health care service was preauthorized
  and coverage is not terminated during that period [unless the
  physician or provider has materially misrepresented the proposed
  health care services or has substantially failed to perform the
  proposed health care services].
         (g-1)  Notwithstanding Section 843.347 or any other law, and
  for the purposes of Subsection (g), a health maintenance
  organization may not require that the physician or provider request
  verification.
         SECTION 2.  Section 1301.135, Insurance Code, is amended by
  amending Subsection (f) and adding Subsection (f-1) to read as
  follows:
         (f)  Unless a physician or health care provider has
  materially misrepresented the proposed medical or health care
  services or has substantially failed to perform the proposed
  medical or health care services, if [If] an insurer has
  preauthorized medical care or health care services, the insurer may
  not deny or reduce payment to the physician or [health care]
  provider for those services based on:
               (1)  medical necessity or appropriateness of care; or
               (2)  eligibility or coverage determinations if the
  proposed medical or health care service is provided to the insured
  before the 31st day after the date the medical or health care
  service was preauthorized and coverage is not terminated during
  that period [unless the physician or provider has materially
  misrepresented the proposed medical or health care services or has
  substantially failed to perform the proposed medical or health care
  services].
         (f-1)  Notwithstanding Section 1301.133 or any other law,
  and for the purposes of Subsection (f), an insurer may not require
  that the physician or health care provider request verification.
         SECTION 3.  The changes in law made by this Act apply only to
  a request for preauthorization of medical care or health care
  services made on or after January 1, 2024, under a health benefit
  plan delivered, issued for delivery, or renewed on or after that
  date.  A request for preauthorization of medical care or health care
  services made before January 1, 2024, or on or after January 1,
  2024, under a health benefit plan delivered, issued for delivery,
  or renewed before that date, is governed by the law as it existed
  immediately before the effective date of this Act, and that law is
  continued in effect for that purpose.
         SECTION 4.  This Act takes effect September 1, 2023.