| |
| |
|
|
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 |
|
|
[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 [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. |