By: Wentworth S.B. No. 1385
A BILL TO BE ENTITLED
AN ACT
1-1 relating to appeal process and elimination of discriminatory
1-2 exclusion of insurers.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Article 21.24-1, Insurance Code, is amended as
1-5 follows:
1-6 (5) "Health insurance policy" or "policy" means an
1-7 individual, group, blanket, or franchise insurance policy, or
1-8 insurance agreement that provides reimbursement or indemnity for
1-9 health care expenses incurred as a result of an accident or
1-10 sickness.
1-11 (6) "Insurer" means an insurance company, association,
1-12 or organization authorized to do business in this state under
1-13 Chapter 3, 8, 10, 11, 12, 13, 14, 15, 18, 19, 20, or 22 of this
1-14 code.
1-15 SECTION 2. Article 21.58A, Insurance Code, is amended as
1-16 follows:
1-17 Sec. 6. APPEAL OF ADVERSE DETERMINATIONS OF UTILIZATION
1-18 REVIEW AGENTS.
1-19 (b) The procedures for appeals shall be reasonable and shall
1-20 include the following:
1-21 (1) a provision that an enrollee, a person acting on
1-22 behalf of the enrollee, or the enrollee's physician or health care
1-23 provider may appeal the adverse determination and shall be
2-1 provided, on request, a clear and concise statement of the clinical
2-2 basis for the adverse determination;
2-3 (2) a list of documents needed to be submitted by the
2-4 appealing party to the utilization review agent for the appeal;
2-5 (3) a provision that appeal decisions shall be made by
2-6 a physician, provided that, if the appeal is denied and within 10
2-7 working days the health care provider sets forth in writing good
2-8 cause for having a particular type of a specialty provider review
2-9 the case, the denial shall be reviewed by a health care provider in
2-10 the same or similar specialty as typically manages the medical
2-11 condition, procedure, or treatment under discussion for review of
2-12 the adverse determination. This health care provider shall not be
2-13 employed by or under contract to the utilization review company or
2-14 its contractor; but rather come from an independent reviewer pool
2-15 whose members are appointed by the appropriate State regulatory
2-16 agency; the cost of the independent review shall be borne equally
2-17 by the utilization review agent and the appealing party;
2-18 (4) in addition to the written appeal, a method for an
2-19 expedited appeal procedure for emergency care denials and denials
2-20 of continued stays for hospitalized patients, which shall include a
2-21 health care provider who has not previously reviewed the case; such
2-22 appeal must be completed no later than one working day following
2-23 the day on which the appeal, including all information necessary to
2-24 complete the appeal, is made to the utilization review agent. This
2-25 health care provider shall not be employed by or under contract to
3-1 the utilization review company or its contractor; but rather come
3-2 from an independent reviewer pool whose members are appointed by
3-3 the appropriate State regulatory agency; the cost of the
3-4 independent review shall be borne equally by the utilization review
3-5 agent and the appealing party;
3-6 (5) written notification to the appealing party of the
3-7 determination of the appeal, as soon as practical, but in no case
3-8 later than 30 days after receiving all the required documentation
3-9 of the appeal. If the appeal is denied, the written notification
3-10 shall include the clinical basis for the appeal's denial and the
3-11 specialty of the physician making the denial.
3-12 SECTION 3. Article 21.58A, Insurance Code is amended as
3-13 follows:
3-14 Sec. 11. Claims reviews of medical necessity. (a) When a
3-15 retrospective review of the medical necessity and appropriateness
3-16 of health care service is made under a health insurance policy or
3-17 plan: (1) such retrospective review shall be based on written
3-18 screening criteria established and periodically updated with
3-19 appropriate involvement from physicians, including practicing
3-20 physicians, and other health care providers; and (2) the payor's
3-21 system for such retrospective review of medical necessity and
3-22 appropriateness shall be under the direction of a physician.
3-23 (b) When an adverse determination is made under a health
3-24 insurance policy or plan based on a retrospective review of the
3-25 medical necessity and appropriateness of the allocation of health
4-1 care resources and services, the payor shall afford the health care
4-2 providers the opportunity to appeal the determination in the same
4-3 manner afforded the enrollee, with the enrollee's consent to act on
4-4 his or her behalf, but in no event shall health care providers be
4-5 precluded from appeal if the enrollee is not reasonably available
4-6 or competent to consent. Such appeal shall not be construed to
4-7 imply or confer on such health care providers any contract rights
4-8 with respect to the enrollee's health insurance policy or plan that
4-9 the health care provider does not otherwise have; the enrolled or
4-10 treatment provider is entitled to an independent review in cases of
4-11 adverse determinations. This review shall come from the approved
4-12 list provided for in 21.58A section 6(3), (4).
4-13 SECTION 4. The importance of this legislation and the
4-14 crowded condition of the calendars in both houses create an
4-15 emergency and an imperative public necessity that the
4-16 constitutional rule requiring bills to be read on three several
4-17 days in each house be suspended, and this rule is hereby suspended,
4-18 and that this Act take effect and be in force from and after its
4-19 passage, and it is so enacted.