AN ACT
1-1 relating to utilization review under health benefit plans and
1-2 health insurance policies.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Section 2, Article 21.58A, Insurance Code, is
1-5 amended to read as follows:
1-6 Sec. 2. Definitions. In this article:
1-7 (1) "Administrative procedure act" means Chapter 2001,
1-8 Government Code [the Administrative Procedure and Texas Register
1-9 Act (Article 6252-13a, Vernon's Texas Civil Statutes)].
1-10 (2) "Administrator" means a person holding a
1-11 certificate of authority under Article 21.07-6 of this code.
1-12 (3) "Adverse determination" means a determination by a
1-13 utilization review agent that the health care services furnished or
1-14 proposed to be furnished to a patient are not medically necessary
1-15 [or not appropriate in the allocation of health care resources].
1-16 (4) ["Board" means the State Board of Insurance.]
1-17 [(5)] "Certificate" means a certificate of
1-18 registration granted by the commissioner [board] to a utilization
1-19 review agent.
1-20 (5) [(6)] "Commissioner" means the commissioner of
1-21 insurance.
1-22 (6) [(7)] "Emergency care" means health care services
1-23 provided in a hospital emergency facility or comparable facility to
2-1 evaluate and stabilize medical conditions of a recent onset and
2-2 severity, including but not limited to severe pain, that would lead
2-3 a prudent layperson possessing an average knoledge of medicine and
2-4 health to believe that his or her condition, sickness, or injury is
2-5 of such a nature that failure to get immediate medical care could
2-6 result in:
2-7 (A) placing the patient's health in serious
2-8 jeopardy;
2-9 (B) serious impairment to bodily functions;
2-10 (C) serious dysfunction of any bodily organ or
2-11 part;
2-12 (D) serious disfigurement; or
2-13 (E) in the case of a pregnant woman, serious
2-14 jeopardy to the health of the fetus [bona fide emergency services
2-15 as defined in Section 2(I), Chapter 397, Acts of the 54th
2-16 Legislature, 1955 (Article 3.70-2, Vernon's Texas Insurance Code)
2-17 and Section 2(t), Texas Health Maintenance Organization Act
2-18 (Article 20A.02, Vernon's Texas Insurance Code)].
2-19 (7) [(8)] "Dental plan" means an insurance policy or
2-20 health benefit plan, including a policy written by a company
2-21 subject to Chapter 20 of this code, that provides coverage for
2-22 expenses for dental services.
2-23 (8) [(9)] "Enrollee" means a person covered by a
2-24 health insurance policy or plan and includes a person who is
2-25 covered as an eligible dependent of another person.
3-1 (9) [(10)] "Health benefit plan" means a plan of
3-2 benefits that defines the coverage provisions for health care for
3-3 enrollees offered or provided by any organization, public or
3-4 private, other than health insurance.
3-5 (10) [(11)] "Health care provider" means any person,
3-6 corporation, facility, or institution licensed by a state to
3-7 provide or otherwise lawfully providing health care services that
3-8 is eligible for independent reimbursement for those services.
3-9 (11) [(12)] "Health insurance policy" means an
3-10 insurance policy, including a policy written by a company subject
3-11 to Chapter 20 of this code, that provides coverage for medical or
3-12 surgical expenses incurred as a result of accident or sickness.
3-13 (12) "Life threatening" means a disease or condition
3-14 for which the likelihood of death is probable unless the course of
3-15 the disease or condition is interrupted.
3-16 (13) "Nurse" means a professional or registered nurse,
3-17 a licensed vocational nurse, or a licensed practical nurse.
3-18 (14) "Open meetings law" means Chapter 551, Government
3-19 Code [271, Acts of the 60th Legislature, Regular Session, 1967
3-20 (Article 6252-17, Vernon's Texas Civil Statutes)].
3-21 (15) "Open records law" means Chapter 552, Government
3-22 Code [424, Acts of the 63rd Legislature, Regular Session, 1973
3-23 (Article 6252-17a, Vernon's Texas Civil Statutes)].
3-24 (16) "Patient" means the enrollee or an eligible
3-25 dependent of the enrollee under a health benefit plan or health
4-1 insurance plan.
4-2 (17) "Payor" means:
4-3 (A) an insurer writing health insurance
4-4 policies;
4-5 (B) any preferred provider organization, health
4-6 maintenance organization, self-insurance plan; or
4-7 (C) any other person or entity which provides,
4-8 offers to provide, or administers hospital, outpatient, medical, or
4-9 other health benefits to persons treated by a health care provider
4-10 in this state pursuant to any policy, plan, or contract.
4-11 (18) "Physician" means a licensed doctor of medicine
4-12 or a doctor of osteopathy.
4-13 (19) "Provider of record" means the physician or other
4-14 health care provider that has primary responsibility for the care,
4-15 treatment, and services rendered to the enrollee and includes any
4-16 health care facility when treatment is rendered on an inpatient or
4-17 outpatient basis.
4-18 (20) "Utilization review" means a system for
4-19 prospective or concurrent review of the medical necessity and
4-20 appropriateness of health care services being provided or proposed
4-21 to be provided to an individual within this state. Utilization
4-22 review shall not include elective requests for clarification of
4-23 coverage.
4-24 (21) "Utilization review agent" means an entity that
4-25 conducts utilization review for:
5-1 (A) an employer with employees in this state who
5-2 are covered under a health benefit plan or health insurance policy;
5-3 (B) a payor; or
5-4 (C) an administrator.
5-5 (22) "Utilization review plan" means the screening
5-6 criteria and utilization review procedures of a utilization review
5-7 agent.
5-8 (23) "Working day" means a weekday, excluding a legal
5-9 holiday.
5-10 SECTION 2. Subsections (b), (d), (e), and (f), Section 3,
5-11 Article 21.58A, Insurance Code, are amended to read as follows:
5-12 (b) The commissioner may only issue a certificate to an
5-13 applicant that has met all the requirements of this article and all
5-14 applicable rules and regulations of the commissioner [board].
5-15 (d) Certification may be renewed biennially by filing, not
5-16 later than March 1, a renewal form with the commissioner
5-17 accompanied by a renewal fee in an amount set by the commissioner
5-18 [board].
5-19 (e) The commissioner shall promulgate certification and
5-20 renewal forms to be filed under this section. The form for initial
5-21 certification must require the following:
5-22 (1) the entity's name, address, telephone number, and
5-23 normal business hours;
5-24 (2) the name and address of an agent for service of
5-25 process in this state;
6-1 (3) a summary of the utilization review plan, but in
6-2 no event shall proprietary details be subject to inclusion in the
6-3 summary;
6-4 (4) information concerning the personnel categories
6-5 that will perform utilization review for the utilization review
6-6 agent;
6-7 (5) a copy of the procedure established by the
6-8 utilization review agent as required by this article for appeal of
6-9 an adverse determination;
6-10 (6) a certification that the utilization review agent
6-11 will comply with the provisions of this article; and
6-12 (7) a copy of the procedures for handling oral and
6-13 written complaints by enrollees, patients, or health care
6-14 providers.
6-15 (f) The commissioner [board] shall establish, administer,
6-16 and enforce the certification and renewal fees under this section
6-17 in amounts not greater than that necessary to cover the cost of
6-18 administration of this article.
6-19 SECTION 3. Subsections (c), (h), (i), (k), (m), and (n),
6-20 Section 4, Article 21.58A, Insurance Code, are amended to read as
6-21 follows:
6-22 (c) Personnel employed by or under contract with the
6-23 utilization review agent to perform utilization review shall be
6-24 appropriately trained and qualified. Personnel who obtain
6-25 information regarding a patient's specific medical condition,
7-1 diagnosis, and treatment options or protocols directly from the
7-2 physician or health care provider, either orally or in writing, and
7-3 who are not physicians shall be nurses, physician assistants, or
7-4 health care providers qualified to provide the service requested by
7-5 the provider [registered records administrators, or accredited
7-6 records technicians, who are either licensed or certified, or shall
7-7 be individuals who have received formal orientation and training in
7-8 accordance with policies and procedures established by the
7-9 utilization review agent to assure compliance with this section,
7-10 and a description of such policies and procedures shall be filed
7-11 with the commissioner]. This provision shall not be interpreted to
7-12 require such qualifications for personnel who perform clerical or
7-13 administrative tasks.
7-14 (h) Utilization review conducted by a utilization review
7-15 agent shall be under the direction of a physician licensed to
7-16 practice medicine by a state licensing agency in the United States.
7-17 (i) Each utilization review agent shall utilize written
7-18 medically acceptable screening criteria and review procedures which
7-19 are established and periodically evaluated and updated with
7-20 appropriate involvement from physicians, including practicing
7-21 physicians, dentists, and other health care providers. Utilization
7-22 review decisions shall be made in accordance with currently
7-23 accepted medical or health care practices, taking into account
7-24 special circumstances of each case that may require deviation from
7-25 the norm stated in the screening criteria. Screening criteria must
8-1 be objective, clinically valid, compatible with established
8-2 principles of health care, and flexible enough to allow deviations
8-3 from the norms when justified on a case-by-case basis. Screening
8-4 criteria must be used to determine only whether to approve the
8-5 requested treatment. Denials must be referred to an appropriate
8-6 physician, dentist, or other health care provider to determine
8-7 medical necessity. Such written screening criteria and review
8-8 procedures shall be available for review and inspection to
8-9 determine appropriateness and compliance as deemed necessary by the
8-10 commissioner and copying as necessary for the commissioner to carry
8-11 out his or her lawful duties under this code, provided, however,
8-12 that any information obtained or acquired under the authority of
8-13 this subsection and article is confidential and privileged and not
8-14 subject to the open records law or subpoena except to the extent
8-15 necessary for the [board or] commissioner to enforce this article.
8-16 (k) Subject to the notice requirements of Section 5 of this
8-17 article, in any instance where the utilization review agent is
8-18 questioning the medical necessity or appropriateness of health care
8-19 services, the health care provider who ordered the services shall
8-20 be afforded a reasonable opportunity to discuss the plan of
8-21 treatment for the patient and the clinical basis for the
8-22 utilization review agent's decision with a physician [or, in the
8-23 case of a dental plan with a dentist,] prior to issuance of an
8-24 adverse determination.
8-25 (m) A utilization review agent shall establish and maintain
9-1 a complaint system that provides reasonable procedures for the
9-2 resolution of oral or written complaints initiated by enrollees,
9-3 patients, or health care providers concerning the utilization
9-4 review and shall maintain records of such [written] complaints for
9-5 three [two] years from the time the complaints are filed. The
9-6 complaint procedure shall include a written response to the
9-7 complainant by the agent within 30 [60] days. The utilization
9-8 review agent shall submit to the commissioner a summary report of
9-9 all complaints at such times and in such forms as the commissioner
9-10 [board] may require and shall permit the commissioner to examine
9-11 the complaints and all relevant documents at any time.
9-12 (n) The utilization review agent may delegate utilization
9-13 review to qualified personnel in the hospital or health care
9-14 facility where the health care services were or are to be provided.
9-15 However, such delegation shall not relieve the utilization review
9-16 agent of full responsibility for compliance with this article,
9-17 including the conduct of those to whom utilization review has been
9-18 delegated.
9-19 SECTION 4. Subsections (c) and (d), Section 5, Article
9-20 21.58A, Insurance Code, are amended to read as follows:
9-21 (c) In the event of an adverse determination, the
9-22 notification by the utilization review agent must include:
9-23 (1) the principal reasons for the adverse
9-24 determination;
9-25 (2) the clinical basis for the adverse determination;
10-1 (3) a description or the source of the screening
10-2 criteria that were utilized as guidelines in making the
10-3 determination; and
10-4 (4) [(3)] a description of the procedure for the
10-5 complaint and appeal process.
10-6 (d) The notification of adverse determination required by
10-7 this section shall be provided by the utilization review agent:
10-8 (1) within one working day by telephone or electronic
10-9 transmission to the provider of record in the case of a patient who
10-10 is hospitalized at the time of the adverse determination, to be
10-11 followed by a letter notifying the patient and the provider of
10-12 record of an adverse determination within three working days; [or]
10-13 (2) within three working days in writing to the
10-14 provider of record and the patient if the patient is not
10-15 hospitalized at the time of the adverse determination; or
10-16 (3) within the time appropriate to the circumstances
10-17 relating to the delivery of the services and the condition of the
10-18 patient, but in no case to exceed one hour from notification when
10-19 denying poststabilization care subsequent to emergency treatment as
10-20 requested by a treating physician or provider. In such
10-21 circumstances, notification shall be provided to the treating
10-22 physician or health care provider.
10-23 SECTION 5. Section 6, Article 212.58A, Insurance Code, is
10-24 amended to read as follows:
10-25 Sec. 6. APPEAL OF ADVERSE DETERMINATIONS OF UTILIZATION
11-1 REVIEW AGENTS. (a) A utilization review agent shall maintain and
11-2 make available a written description of [an] appeal procedures
11-3 involving [procedure of] an adverse determination.
11-4 (b) The procedures for appeals shall be reasonable and shall
11-5 include the following:
11-6 (1) a provision that an enrollee, a person acting on
11-7 behalf of the enrollee, or the enrollee's physician or health care
11-8 provider may appeal the adverse determination orally or in writing
11-9 [and shall be provided, on request, a clear and concise statement
11-10 of the clinical basis for the adverse determination];
11-11 (2) a provision that, within five working days from
11-12 receipt of the appeal, the utilization review agent shall send to
11-13 the appealing party a letter acknowledging the date of the
11-14 utilization review agent's receipt of the appeal and include a
11-15 reasonable list of documents needed to be submitted by the
11-16 appealing party to the utilization review agent for the appeal.
11-17 Such letter must also include provisions listed in this subsection.
11-18 When the utilization review agent receives an oral appeal of
11-19 adverse determination, the utilization review agent shall send a
11-20 one-page appeal form to the appealing party;
11-21 (3) a provision that appeal decisions shall be made by
11-22 a physician, provided that, if the appeal is denied and within 10
11-23 working days the health care provider sets forth in writing good
11-24 cause for having a particular type of a specialty provider review
11-25 the case, the denial shall be reviewed by a health care provider in
12-1 the same or similar specialty as typically manages the medical,
12-2 dental, or specialty condition, procedure, or treatment under
12-3 discussion for review of the adverse determination, and such
12-4 specialty review shall be completed within 15 working days of
12-5 receipt of the request;
12-6 (4) in addition to the written appeal, a method for an
12-7 expedited appeal procedure for emergency care denials, denials of
12-8 care for life-threatening conditions, and denials of continued
12-9 stays for hospitalized patients. Such procedure[, which] shall
12-10 include a review by a health care provider who has not previously
12-11 reviewed the case who is of the same or a similar specialty as
12-12 typically manages the medical condition, procedure, or treatment
12-13 under review. The time frame in which[;] such appeal must be
12-14 completed shall be based on the medical or dental immediacy of the
12-15 condition, procedure, or treatment, but may in no event exceed one
12-16 working day from the date [no later than one working day following
12-17 the day on which the appeal, including] all information necessary
12-18 to complete the appeal[,] is received [made to the utilization
12-19 review agent]; [and]
12-20 (5) a provision that after the utilization review
12-21 agent has sought review of the appeal of the adverse determination,
12-22 the utilization review agent shall issue a response letter to the
12-23 patient, a person acting on behalf of the patient, or the patient's
12-24 physician or health care provider explaining the resolution of the
12-25 appeal. Such letter shall include a statement of the specific
13-1 medical, dental, or contractual reasons for the resolution, the
13-2 clinical basis for such decision, and the specialization of any
13-3 physician or other provider consulted; and
13-4 (6) written notification to the appealing party of the
13-5 determination of the appeal, as soon as practical, but in no case
13-6 later than 30 days after the date the utilization review agent
13-7 receives the appeal [receiving all the required documentation of
13-8 the appeal. If the appeal is denied, the written notification
13-9 shall include the clinical basis for the appeal's denial and the
13-10 specialty of the physician making the denial].
13-11 SECTION 6. Section 7, Article 21.58A, Insurance Code, is
13-12 amended by adding Subsection (c) to read as follows:
13-13 (c) A utilization review agent must provide a written
13-14 description to the commissioner setting forth the procedures to be
13-15 used when responding to poststabilization care subsequent to
13-16 emergency treatment as requested by a treating physician or health
13-17 care provider.
13-18 SECTION 7. Section 8, Article 21.58A, Insurance Code, is
13-19 amended to read as follows:
13-20 Sec. 8. CONFIDENTIALITY. (a) A utilization review agent
13-21 shall preserve the confidentiality of individual medical records to
13-22 the extent required by law.
13-23 (b) A utilization review agent may not disclose or publish
13-24 individual medical records, personal information, or other
13-25 confidential information about a patient obtained in the
14-1 performance of utilization review without the prior written consent
14-2 of the patient or as otherwise required by law. If such
14-3 authorization is submitted by anyone other than the individual who
14-4 is the subject of the personal or confidential information
14-5 requested, such authorization must:
14-6 (1) be dated; and
14-7 (2) contain the signature of the individual who is the
14-8 subject of the personal or confidential information requested. The
14-9 signature must have been obtained one year or less prior to the
14-10 date the disclosure is sought or the authorization is invalid.
14-11 (c) A utilization review agent may provide confidential
14-12 information to a third party under contract or affiliated with the
14-13 utilization review agent for the sole purpose of performing or
14-14 assisting with utilization review. Information provided to third
14-15 parties shall remain confidential.
14-16 (d) If an individual submits a written request to the
14-17 utilization review agent for access to recorded personal
14-18 information about the individual, the utilization review agent
14-19 shall within 10 business days from the date such request is
14-20 received:
14-21 (1) inform the individual submitting the request of
14-22 the nature and substance of the recorded personal information in
14-23 writing; and
14-24 (2) permit the individual to see and copy, in person,
14-25 the recorded personal information pertaining to the individual or
15-1 to obtain a copy of the recorded personal information by mail, at
15-2 the discretion of the individual, unless the recorded personal
15-3 information is in coded form, in which case an accurate translation
15-4 in plain language shall be provided in writing.
15-5 (e) A utilization review agent's charges for providing a
15-6 copy of recorded personal information to individuals shall be
15-7 reasonable, as determined by rule of the commissioner, and may not
15-8 include any costs that are otherwise recouped as part of the charge
15-9 for utilization review.
15-10 (f) [(c)] The utilization review agent may not publish data
15-11 which identifies a particular physician or health care provider,
15-12 including any quality review studies or performance tracking data,
15-13 without prior written notice to the involved provider. This
15-14 prohibition does not apply to internal systems or reports used by
15-15 the utilization review agent.
15-16 (g) [(d)] Documents in the custody of the utilization review
15-17 agent that contain confidential patient information or physician or
15-18 health care provider financial data shall be destroyed by a method
15-19 which induces complete destruction of the information when the
15-20 agent determines the information is no longer needed.
15-21 (h) [(e)] All patient, physician, and health care provider
15-22 data shall be maintained by the utilization review agent in a
15-23 confidential manner which prevents unauthorized disclosure to third
15-24 parties. Nothing in this article shall be construed to allow a
15-25 utilization review agent to take actions that violate a state or
16-1 federal statute or regulation concerning confidentiality of patient
16-2 records.
16-3 (i) Notwithstanding the provisions in Subsections (a)
16-4 through (h) of this section, the utilization review agent shall
16-5 provide to the commissioner on request individual medical records
16-6 or other confidential information for determination of compliance
16-7 with this article. The information is confidential and privileged
16-8 and is not subject to the open records law, Chapter 552, Government
16-9 Code, or to subpoena, except to the extent necessary to enable the
16-10 commissioner to enforce this article.
16-11 SECTION 8. Subsections (a), (b), and (d), Section 9, Article
16-12 21.58A, Insurance Code, is amended to read as follows:
16-13 (a) If the commissioner believes that any person or entity
16-14 conducting utilization review pursuant to this article is in
16-15 violation of [a utilization review agent has violated or is
16-16 violating] this article or applicable regulations, the commissioner
16-17 shall notify the utilization review agent, health maintenance
16-18 organization, or insurer of the alleged violation and may compel
16-19 the production of any and all documents or other information as
16-20 necessary in order to determine whether or not such violation has
16-21 taken place [provided by this code].
16-22 (b) The commissioner may initiate the proceedings under this
16-23 section [after the 30th day after the date the commissioner
16-24 notifies the agent as required by Subsection (a) of this section].
16-25 (d) If [after notice and hearing] the commissioner
17-1 determines that the utilization review agent, health maintenance
17-2 organization, insurer, or other person or entity conducting
17-3 utilization review pursuant to this article has violated or is
17-4 violating any provision of this article, the commissioner may:
17-5 (1) impose sanctions under Section 7, Article 1.10 of
17-6 this code; [or]
17-7 (2) issue a cease and desist order under Article 1.10A
17-8 of this code; or
17-9 (3) assess administrative penalties under Article
17-10 1.10E of this code.
17-11 SECTION 9. Section 13, Article 21.58A, Insurance Code, is
17-12 amended to read as follows:
17-13 Sec. 13. Authority to adopt rules. The commissioner may
17-14 [board shall] have the authority to adopt rules and regulations to
17-15 implement the provisions of this article. The commissioner [board]
17-16 shall appoint an [11-member] advisory committee to advise the
17-17 commissioner [board] in developing rules and regulations to
17-18 administer this article as authorized by Section 2001.031,
17-19 Government Code. The committee's deliberations shall be subject to
17-20 the open meetings law. The committee shall include the public
17-21 counsel and one representative for each of the following:
17-22 insurance companies, health maintenance organizations, group
17-23 hospital service corporations, utilization review agents,
17-24 employers, consumer organizations, physicians, dentists, hospitals,
17-25 registered nurses, and other health care providers.
18-1 SECTION 10. Section 14, Article 21.58A, Insurance Code, is
18-2 amended by amending Subsections (b), (e), (g), and (h) and adding
18-3 Subsection (j) to read as follows:
18-4 (b)(1) This article shall not apply to any contract with the
18-5 federal government for utilization review of patients eligible for
18-6 services under Title XVIII or XIX of the Social Security Act (42
18-7 U.S.C. Section 1395 et seq. or Section 1396 et seq.).
18-8 (2) Except as provided by Subsection (g) of this
18-9 section, this [This] article shall not apply to the Texas Medicaid
18-10 Program, the chronically ill and disabled children's services
18-11 program created pursuant to Chapter 35, Health and Safety Code, any
18-12 program administered under Title 2, Human Resources Code, any
18-13 program of the Texas Department of Mental Health and Mental
18-14 Retardation, or any program of the Texas Department of Criminal
18-15 Justice.
18-16 (e) This article shall not apply to the terms or benefits of
18-17 employee welfare benefit plans as defined in Section 3(1) [31(I)]
18-18 of the Employee Retirement Income Security Act of 1974 (29 U.S.C.
18-19 Section 1002(1) [1002]).
18-20 (g) A health maintenance organization, including a health
18-21 maintenance organization that contracts with the Health and Human
18-22 Services Commission or an agency operating part of the state
18-23 Medicaid managed care program to provide health care services to
18-24 recipients of medical assistance under Chapter 32, Human Resources
18-25 Code, is [not] subject to this article except as expressly provided
19-1 in this subsection and Subsection (i) of this section. If such
19-2 health maintenance organization performs utilization review as
19-3 defined herein, it shall, as a condition of licensure:
19-4 (1) comply with [Sections 4(b), (c), (e), (f), (h),
19-5 (i), and (l) of] this article, except Sections 3 and 10, and the
19-6 commissioner [board] shall promulgate rules for appropriate
19-7 verification and enforcement of compliance. However, nothing in
19-8 this article shall be construed to prohibit or limit the
19-9 distribution of a proportion of the savings from the reduction or
19-10 elimination of unnecessary medical services, treatment, supplies,
19-11 confinements, or days of confinement in a health care facility
19-12 through profit sharing, bonus, or withhold arrangements to
19-13 participating physicians or participating health care providers for
19-14 rendering health care services to enrollees; and
19-15 (2) [establish and maintain a system for:]
19-16 [(A) handling and responding to complaints by
19-17 enrollees, patients, or health care providers;]
19-18 [(B) providing health care providers with notice
19-19 of medical necessity or program requirements that have not been
19-20 met, including a reasonable opportunity to discuss the plan of
19-21 treatment and clinical basis for a utilization review determination
19-22 with a physician; and]
19-23 [(C) providing the enrollee, patient, and health
19-24 care provider an opportunity to appeal the determination; and]
19-25 [(3)] submit to assessment of maintenance taxes under
20-1 Article 20A.33, Texas Health Maintenance Organization Act (Article
20-2 20A.33, Vernon's Texas Insurance Code), to cover the costs of
20-3 administering compliance of health maintenance organizations under
20-4 this section.
20-5 (h) An insurer which delivers or issues for delivery a
20-6 health insurance policy in Texas and is subject to this code is
20-7 [not] subject to this article except as expressly provided in this
20-8 subsection and Subsection (i) of this section. If an insurer
20-9 performs utilization review as defined herein it shall, as a
20-10 condition of licensure, comply with [Sections 4 through 8 of] this
20-11 article, except Sections 3 and 10, and the commissioner [board]
20-12 shall promulgate rules for appropriate verification and enforcement
20-13 of compliance. Such insurers shall be subject to assessment of
20-14 maintenance tax under Article 4.17 of this code to cover the costs
20-15 of administering compliance of insurers under this section.
20-16 (j) A specialty utilization review agent is not subject to
20-17 Section 4(b), (c), (h), or (k) or Section 6(b)(3) of this article.
20-18 For purposes of this subsection, a specialty utilization review
20-19 agent means a utilization review agent that conducts utilization
20-20 review for specialty health care services, including but not
20-21 limited to dentistry, chiropractic, or physical therapy. A
20-22 specialty utilization review agent shall comply with the following
20-23 requirements:
20-24 (1) the utilization review plan, including
20-25 reconsideration and appeal requirements, shall be reviewed by a
21-1 health care provider of the appropriate specialty and conducted in
21-2 accordance with standards developed with input from a health care
21-3 provider of the appropriate specialty;
21-4 (2) personnel employed by or under contract with a
21-5 specialty utilization review agent to perform utilization review
21-6 shall be appropriately trained and qualified. Personnel who obtain
21-7 information directly from the physician or health care provider,
21-8 either orally or in writing, shall be nurses, physician assistants,
21-9 or other health care providers of the same specialty as the
21-10 utilization review agent and who are licensed or otherwise
21-11 authorized to provide the specialty health care service by a state
21-12 licensing agency in the United States, except that this provision
21-13 does not require those qualifications for personnel who perform
21-14 solely clerical or administrative tasks;
21-15 (3) utilization review conducted by a specialty
21-16 utilization review agent shall be conducted under the direction of
21-17 a health care provider of the same specialty and shall be licensed
21-18 or otherwise authorized to provide the specialty health care
21-19 service by a state licensing agency in the United States;
21-20 (4) subject to the notice requirements of Section 5 of
21-21 this article, in any instance where the specialty utilization
21-22 review agent questions the medical necessity or appropriateness of
21-23 health care services, the health care provider who ordered the
21-24 services shall, prior to the issuance of an adverse determination,
21-25 be afforded a reasonable opportunity to discuss the plan of
22-1 treatment for the patient and the clinical basis for the decision
22-2 of the utilization review agent with a health care provider of the
22-3 same specialty as the utilization review agent; and
22-4 (5) appeal decisions shall be made by a physician or
22-5 health care provider in the same or a similar specialty as
22-6 typically manages the medical, dental, or specialty condition,
22-7 procedure, or treatment under discussion for review of the adverse
22-8 determination.
22-9 SECTION 11. This Act takes effect September 1, 1997.
22-10 SECTION 12. The importance of this legislation and the
22-11 crowded condition of the calendars in both houses create an
22-12 emergency and an imperative public necessity that the
22-13 constitutional rule requiring bills to be read on three several
22-14 days in each house be suspended, and this rule is hereby suspended.
S.B. No. 384
________________________________ ________________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 384 passed the Senate on
March 6, 1997, by a viva-voce vote; May 28, 1997, Senate refused to
concur in House amendments and requested appointment of Conference
Committee; May 29, 1997, House granted request of the Senate;
June 1, 1997, Senate adopted Conference Committee Report by a
viva-voce vote.
_______________________________
Secretary of the Senate
I hereby certify that S.B. No. 384 passed the House, with
amendments, on May 25, 1997, by a non-record vote; May 29, 1997,
House granted request of the Senate for appointment of Conference
Committee; June 1, 1997, House adopted Conference Committee Report
by a non-record vote.
_______________________________
Chief Clerk of the House
Approved:
________________________________
Date
________________________________
Governor