Enrolled Bill Summary

            House Bill 1862 amends the Insurance Code and the Texas Health Maintenance Organization Act to establish requirements, procedures, and deadlines for the timely submission and prompt handling of claims and for the prompt payment of physicians and medical care and health care providers by insurers and health maintenance organizations (HMOs) under certain health benefits plans. The bill requires a physician or provider to submit a claim not later than the 95th day after the date the medical care or health care service was provided or else forfeit the right to payment for that service. The bill defines "clean claim," specifying the use of standard, nationally accepted forms for medical payment claims and prohibiting an insurer or HMO from requiring the submission of information other than that for a data field included on those forms, and it provides that a claim is considered filed within specific time frames based on the manner and means in which the claim is submitted to the insurer or HMO. The bill requires an insurer or HMO that fails to pay, before the 45-day deadline for payment, all or any part of the claim that is eligible for payment to pay either the full amount of the billed charges or two times the contracted rate, plus interest on the applicable amount at a 15 percent annual percentage rate, whichever total is the lesser of the two. The bill establishes requirements, procedures, and deadlines for the investigation and determination by an insurer or HMO of a claim's eligibility for payment, but it provides that such investigation and determination do not extend the deadline for determining the claim's eligibility for payment. The bill allows a preferred provider to recover court costs as well as reasonable attorney's fees in an action to recover payment. The bill also establishes situations in which an insurer or HMO may recover an overpayment. The bill establishes requirements for the timely verification by an insurer or HMO of the eligibility of a particular health care service for payment when a physician or provider requests such verification. The bill allows the issuer of a health benefit plan to require a health care professional or facility to submit certain information electronically. The bill provides for penalties for noncompliance with certain provisions and prohibits provisions from being waived, voided, or nullified by contract.