75R11075 SAW-F
By Nelson S.B. No. 384
Substitute the following for S.B. No. 384:
By Smithee C.S.S.B. No. 384
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to utilization review under health benefit plans and
1-3 health insurance policies.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Section 2, Article 21.58A, Insurance Code, is
1-6 amended to read as follows:
1-7 Sec. 2. DEFINITIONS. In this article:
1-8 (1) "Administrative procedure act" means Chapter 2001,
1-9 Government Code [the Administrative Procedure and Texas Register
1-10 Act (Article 6252-13a, Vernon's Texas Civil Statutes)].
1-11 (2) "Administrator" means a person holding a
1-12 certificate of authority under Article 21.07-6 of this code.
1-13 (3) "Adverse determination" means a determination by a
1-14 utilization review agent that the health care services furnished or
1-15 proposed to be furnished to a patient are not medically necessary
1-16 or not appropriate in the allocation of health care resources.
1-17 (4) ["Board" means the State Board of Insurance.]
1-18 [(5)] "Certificate" means a certificate of
1-19 registration granted by the commissioner [board] to a utilization
1-20 review agent.
1-21 (5) [(6)] "Commissioner" means the commissioner of
1-22 insurance.
1-23 (6) [(7)] "Emergency care" means health care services
1-24 provided in a hospital emergency facility or comparable facility to
2-1 evaluate and stabilize medical conditions of recent onset and
2-2 severity, including severe pain, that would lead a prudent
2-3 layperson possessing an average knowledge of medicine and health to
2-4 believe that his or her condition, sickness, or injury is of such a
2-5 nature that failure to get immediate medical care could result in:
2-6 (A) placing the person's health in serious
2-7 jeopardy;
2-8 (B) serious impairment to bodily functions;
2-9 (C) serious dysfunction of any bodily organ or
2-10 part;
2-11 (D) serious disfigurement; or
2-12 (E) in the case of a pregnant woman, serious
2-13 jeopardy to the health of the fetus [bona fide emergency services
2-14 as defined in Section 2(I), Chapter 397, Acts of the 54th
2-15 Legislature, 1955 (Article 3.70-2, Vernon's Texas Insurance Code)
2-16 and Section 2(t), Texas Health Maintenance Organization Act
2-17 (Article 20A.02, Vernon's Texas Insurance Code)].
2-18 (7) [(8)] "Dental plan" means an insurance policy or
2-19 health benefit plan, including a policy written by a company
2-20 subject to Chapter 20 of this code, that provides coverage for
2-21 expenses for dental services.
2-22 (8) [(9)] "Enrollee" means a person covered by a
2-23 health insurance policy or plan and includes a person who is
2-24 covered as an eligible dependent of another person.
2-25 (9) [(10)] "Health benefit plan" means a plan of
2-26 benefits that defines the coverage provisions for health care for
2-27 enrollees offered or provided by any organization, public or
3-1 private, other than health insurance. The term does not include a
3-2 plan that provides coverage only for a specified accident or
3-3 disease or a hospital indemnity, Medicare supplement, long-term
3-4 care, or other limited health insurance policy.
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 condition" means a condition
3-14 from which the likelihood of death is high unless the course of the
3-15 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
3-26 insurance plan.
3-27 (17) "Payor" means:
4-1 (A) an insurer writing health insurance
4-2 policies;
4-3 (B) any preferred provider organization, health
4-4 maintenance organization, self-insurance plan; or
4-5 (C) any other person or entity which provides,
4-6 offers to provide, or administers hospital, outpatient, medical, or
4-7 other health benefits to persons treated by a health care provider
4-8 in this state pursuant to any policy, plan, or contract.
4-9 (18) "Physician" means a licensed doctor of medicine
4-10 or a doctor of osteopathy.
4-11 (19) "Provider of record" means the physician or other
4-12 health care provider that has primary responsibility for the care,
4-13 treatment, and services rendered to the enrollee and includes any
4-14 health care facility when treatment is rendered on an inpatient or
4-15 outpatient basis.
4-16 (20) "Utilization review" means a system for
4-17 prospective or concurrent review of the medical necessity and
4-18 appropriateness of health care services being provided or proposed
4-19 to be provided to an individual within this state. Utilization
4-20 review shall not include elective requests for clarification of
4-21 coverage.
4-22 (21) "Utilization review agent" means an entity that
4-23 conducts utilization review for:
4-24 (A) an employer with employees in this state who
4-25 are covered under a health benefit plan or health insurance policy;
4-26 (B) a payor; or
4-27 (C) an administrator.
5-1 (22) "Utilization review plan" means the screening
5-2 criteria and utilization review procedures of a utilization review
5-3 agent.
5-4 (23) "Working day" means a weekday, excluding a legal
5-5 holiday.
5-6 SECTION 2. Sections 3(b), (d), (e), and (f), Article 21.58A,
5-7 Insurance Code, are amended to read as follows:
5-8 (b) The commissioner may only issue a certificate to an
5-9 applicant that has met all the requirements of this article and all
5-10 applicable rules and regulations of the commissioner [board].
5-11 (d) Certification may be renewed biennially by filing, not
5-12 later than March 1, a renewal form with the commissioner
5-13 accompanied by a renewal fee in an amount set by the commissioner
5-14 [board].
5-15 (e) The commissioner shall promulgate certification and
5-16 renewal forms to be filed under this section. The form for initial
5-17 certification must require the following:
5-18 (1) the entity's name, address, telephone number, and
5-19 normal business hours;
5-20 (2) the name and address of an agent for service of
5-21 process in this state;
5-22 (3) a summary of the utilization review plan, but in
5-23 no event shall proprietary details be subject to inclusion in the
5-24 summary;
5-25 (4) information concerning the personnel categories
5-26 that will perform utilization review for the utilization review
5-27 agent;
6-1 (5) a copy of the procedure established by the
6-2 utilization review agent as required by this article for appeal of
6-3 an adverse determination;
6-4 (6) a certification that the utilization review agent
6-5 will comply with the provisions of this article; and
6-6 (7) a copy of the procedures for handling oral and
6-7 written complaints by enrollees, patients, or health care
6-8 providers.
6-9 (f) The commissioner [board] shall establish, administer,
6-10 and enforce the certification and renewal fees under this section
6-11 in amounts not greater than that necessary to cover the cost of
6-12 administration of this article.
6-13 SECTION 3. Sections 4(c), (h), (i), (k), (m), and (n),
6-14 Article 21.58A, Insurance Code, are amended to read as follows:
6-15 (c) Personnel employed by or under contract with the
6-16 utilization review agent to perform utilization review shall be
6-17 appropriately trained and qualified. Personnel who obtain
6-18 information regarding a patient's specific medical condition,
6-19 diagnosis, and treatment options or protocols directly from the
6-20 physician or health care provider, either orally or in writing, and
6-21 who are not physicians shall be nurses or[,] physician assistants
6-22 or mental health providers qualified to provide the service
6-23 requested by the provider [, registered records administrators, or
6-24 accredited records technicians, who are either licensed or
6-25 certified, or shall be individuals who have received formal
6-26 orientation and training in accordance with policies and procedures
6-27 established by the utilization review agent to assure compliance
7-1 with this section, and a description of such policies and
7-2 procedures shall be filed with the commissioner]. This provision
7-3 shall not be interpreted to require such qualifications for
7-4 personnel who perform clerical or administrative tasks.
7-5 (h) Utilization review conducted by a utilization review
7-6 agent shall be under the direction of a physician licensed to
7-7 practice medicine in this state [by a state licensing agency in the
7-8 United States].
7-9 (i) Each utilization review agent shall utilize written
7-10 medically acceptable screening criteria and review procedures which
7-11 are established and periodically evaluated and updated with
7-12 appropriate involvement from physicians, including practicing
7-13 physicians, dentists, and other health care providers. Utilization
7-14 review decisions shall be made in accordance with currently
7-15 accepted medical, mental health, or health or mental health care
7-16 practices, taking into account special circumstances of each case
7-17 that may require deviation from the norm stated in the screening
7-18 criteria. Screening criteria must be objective, clinically valid,
7-19 compatible with established principles of health or mental health
7-20 care, and flexible enough to allow deviations from the norms when
7-21 justified on a case-by-case basis. Screening criteria must be used
7-22 to determine only whether to approve the requested treatment.
7-23 Denials must be referred to an appropriate physician, dentist, or
7-24 other health or mental health care provider to determine medical
7-25 necessity. Such written screening criteria and review procedures
7-26 shall be available for review and inspection to determine
7-27 appropriateness and compliance as deemed necessary by the
8-1 commissioner and copying as necessary for the commissioner to carry
8-2 out his or her lawful duties under this code, provided, however,
8-3 that any information obtained or acquired under the authority of
8-4 this subsection and article is confidential and privileged and not
8-5 subject to the open records law or subpoena except to the extent
8-6 necessary for the [board or] commissioner to enforce this article.
8-7 (k) Subject to the notice requirements of Section 5 of this
8-8 article, in any instance where the utilization review agent is
8-9 questioning the medical necessity or appropriateness of health care
8-10 services, the health care provider who ordered the services shall
8-11 be afforded a reasonable opportunity to discuss the plan of
8-12 treatment for the patient and the clinical basis for the
8-13 utilization review agent's decision with a physician [or, in the
8-14 case of a dental plan with a dentist,] prior to issuance of an
8-15 adverse determination.
8-16 (m) A utilization review agent shall establish and maintain
8-17 a complaint system that provides reasonable procedures for the
8-18 resolution of oral or written complaints initiated by enrollees,
8-19 patients, or health care providers concerning the utilization
8-20 review and shall maintain records of the [such written] complaints
8-21 for three [two] years from the time the complaints are filed. The
8-22 complaint procedure shall include a written response to the
8-23 complainant by the agent within 30 [60] days. The utilization
8-24 review agent shall submit to the commissioner a summary report of
8-25 all complaints at such times and in such forms as the commissioner
8-26 [board] may require and shall permit the commissioner to examine
8-27 the complaints and all relevant documents at any time.
9-1 (n) The utilization review agent may delegate utilization
9-2 review to qualified personnel in the hospital or health care
9-3 facility where the health care services were or are to be provided.
9-4 Delegation does not relieve the utilization review agent of full
9-5 responsibility for compliance with this article, including
9-6 responsibility for the conduct of those to whom utilization review
9-7 has been delegated.
9-8 SECTION 4. Sections 5(c) and (d), Article 21.58A, Insurance
9-9 Code, are amended to read as follows:
9-10 (c) In the event of an adverse determination, the
9-11 notification by the utilization review agent must include:
9-12 (1) the principal reasons for the adverse
9-13 determination;
9-14 (2) the clinical basis for the adverse determination;
9-15 (3) a description or the source of the screening
9-16 criteria that were utilized as guidelines in making the
9-17 determination; and
9-18 (4) [(3)] a description of the procedure for complaint
9-19 and appeal.
9-20 (d) The notification of adverse determination required by
9-21 this section shall be provided by the utilization review agent:
9-22 (1) within one working day by telephone or electronic
9-23 transmission to the provider of record in the case of a patient who
9-24 is hospitalized at the time of the adverse determination, to be
9-25 followed within three working days by a letter notifying the
9-26 patient and the provider of record of an adverse determination;
9-27 [or]
10-1 (2) within three working days in writing to the
10-2 provider of record and the patient if the patient is not
10-3 hospitalized at the time of the adverse determination; or
10-4 (3) within a time period appropriate to the
10-5 circumstances of the service delivery and the patient's condition,
10-6 not to exceed one hour when the adverse determination relates to
10-7 poststabilization care after emergency treatment requested by a
10-8 treating physician or provider, under which circumstances
10-9 notification shall be provided to the treating physician or health
10-10 care provider.
10-11 SECTION 5. Section 6, Article 21.58A, Insurance Code, is
10-12 amended to read as follows:
10-13 Sec. 6. APPEAL OF ADVERSE DETERMINATIONS OF UTILIZATION
10-14 REVIEW AGENTS. (a) A utilization review agent shall maintain and
10-15 make available a written description of procedures for [an] appeal
10-16 [procedure] of an adverse determination.
10-17 (b) The procedures for appeals shall be reasonable and shall
10-18 include the following:
10-19 (1) a provision that an enrollee, a person acting on
10-20 behalf of the enrollee, or the enrollee's physician or health care
10-21 provider may appeal the adverse determination orally or in writing
10-22 [and shall be provided, on request, a clear and concise statement
10-23 of the clinical basis for the adverse determination];
10-24 (2) a provision that, within five working days from
10-25 receipt of the appeal, the utilization review agent shall send to
10-26 the appealing party a letter acknowledging the date of the
10-27 utilization review agent's receipt of the appeal and including a
11-1 reasonable list of documents needed to be submitted by the
11-2 appealing party to the utilization review agent for the appeal and
11-3 information about the appeal requirements of this subsection,
11-4 unless the utilization review agent receives an oral appeal of
11-5 adverse determination, in which case the utilization review agent
11-6 shall send a one-page appeal form to the appealing party;
11-7 (3) a provision that appeal decisions shall be made by
11-8 a physician, provided that, if the appeal is denied and within 10
11-9 working days the health care provider sets forth in writing good
11-10 cause for having a particular type of a specialty provider review
11-11 the case, the denial shall be reviewed by a health care provider in
11-12 the same or similar specialty as typically manages the medical,
11-13 dental, mental health, or specialty condition, procedure, or
11-14 treatment under discussion for review of the adverse determination,
11-15 and that the specialty review shall be completed within 15 working
11-16 days of receipt of the request;
11-17 (4) in addition to the written appeal, [a method for]
11-18 an expedited appeal procedure for emergency care denials, denials
11-19 of care for life-threatening conditions, and denials of continued
11-20 stays for hospitalized patients that [, which] shall include a
11-21 review by a health care provider who has not previously reviewed
11-22 the case and who is of the same or a similar specialty as a health
11-23 care provider who typically manages the medical condition,
11-24 procedure, or treatment under review [; such appeal must be]
11-25 completed in a period based on the medical or dental immediacy of
11-26 the condition, procedure, or treatment not to exceed one working
11-27 day from the date [no later than one working day following the day
12-1 on which the appeal], [including] all information necessary to
12-2 complete the appeal[,] is received [made to the utilization review
12-3 agent]; [and]
12-4 (5) a provision that after the utilization review
12-5 agent has sought review of the appeal of the adverse determination,
12-6 the utilization review agent shall issue a response letter to the
12-7 patient, a person acting on behalf of the patient, or the patient's
12-8 physician or health care provider explaining the resolution of the
12-9 appeal and including a statement of the specific medical, dental,
12-10 or contractual reasons for the resolution, the clinical basis for
12-11 the decision, and the specialization of any physician or other
12-12 provider consulted; and
12-13 (6) written notification to the appealing party of the
12-14 determination of the appeal, as soon as practical, but in no case
12-15 later than 30 days after the date the utilization review agent
12-16 receives the appeal [receiving all the required documentation of
12-17 the appeal. If the appeal is denied, the written notification
12-18 shall include the clinical basis for the appeal's denial and the
12-19 specialty of the physician making the denial].
12-20 SECTION 6. Section 7, Article 21.58A, Insurance Code, is
12-21 amended by adding Subsection (c) to read as follows:
12-22 (c) A utilization review agent must provide to the
12-23 commissioner a written description of the procedures to be used
12-24 when responding to poststabilization care after emergency treatment
12-25 requested by a treating physician or health care provider.
12-26 SECTION 7. Section 8, Article 21.58A, Insurance Code, is
12-27 amended to read as follows:
13-1 Sec. 8. CONFIDENTIALITY. (a) A utilization review agent
13-2 shall preserve the confidentiality of individual medical records to
13-3 the extent required by law.
13-4 (b) A utilization review agent may not disclose or publish
13-5 individual medical records, personal information, or other
13-6 confidential information about a patient obtained in the
13-7 performance of utilization review without the prior written consent
13-8 of the patient or as otherwise required by law. If the
13-9 authorization is submitted by a person other than the individual
13-10 who is the subject of the personal or confidential information
13-11 requested, the authorization must be:
13-12 (1) dated; and
13-13 (2) signed by the individual who is the subject of the
13-14 personal or confidential information requested not later than one
13-15 year before the date the disclosure is sought.
13-16 (c) A utilization review agent may provide confidential
13-17 information to a third party under contract or affiliated with the
13-18 utilization review agent for the sole purpose of performing or
13-19 assisting with utilization review. Information provided to third
13-20 parties shall remain confidential.
13-21 (d) If an individual submits a written request to the
13-22 utilization review agent for access to recorded personal
13-23 information about the individual, the utilization review agent
13-24 shall not later than the 10th business day after the date the
13-25 request is received:
13-26 (1) give written notice to the individual submitting
13-27 the request of the nature and substance of the recorded personal
14-1 information; and
14-2 (2) permit the individual to see and personally copy
14-3 the recorded personal information pertaining to the individual or
14-4 to obtain a copy of the recorded personal information by mail, at
14-5 the discretion of the individual, unless the recorded personal
14-6 information is in coded form, in which case the agent shall provide
14-7 an accurate written translation in plain language.
14-8 (e) A utilization review agent's charges for providing a
14-9 copy of recorded personal information to individuals shall be
14-10 reasonable, as determined by rule of the commissioner, and may not
14-11 include any costs that are otherwise recouped as part of the charge
14-12 for utilization review.
14-13 (f) [(c)] The utilization review agent may not publish data
14-14 which identifies a particular physician or health care provider,
14-15 including any quality review studies or performance tracking data,
14-16 without prior written notice to the involved provider. This
14-17 prohibition does not apply to internal systems or reports used by
14-18 the utilization review agent.
14-19 (g) [(d)] Documents in the custody of the utilization review
14-20 agent that contain confidential patient information or physician or
14-21 health care provider financial data shall be destroyed by a method
14-22 which induces complete destruction of the information when the
14-23 agent determines the information is no longer needed.
14-24 (h) [(e)] All patient, physician, and health care provider
14-25 data shall be maintained by the utilization review agent in a
14-26 confidential manner which prevents unauthorized disclosure to third
14-27 parties. Nothing in this article shall be construed to allow a
15-1 utilization review agent to take actions that violate a state or
15-2 federal statute or regulation concerning confidentiality of patient
15-3 records.
15-4 (i) Notwithstanding the provisions in Subsections (a)
15-5 through (h) of this section, the utilization review agent shall
15-6 provide to the commissioner on request individual medical records
15-7 or other confidential information for determination of compliance
15-8 with this article. The information is confidential and privileged
15-9 and is not subject to the open records law or to subpoena, except
15-10 to the extent necessary for the commissioner to enforce this
15-11 article.
15-12 (j) Notwithstanding any other provision of this article, a
15-13 utilization review agent may not require as a condition of
15-14 treatment approval or for any other reason the observation of a
15-15 psychotherapy session or the submission or review of a mental
15-16 health therapist's process or progress notes.
15-17 SECTION 8. Sections 9(a), (b), and (d), Article 21.58A,
15-18 Insurance Code, are amended to read as follows:
15-19 (a) If the commissioner believes that any person or entity
15-20 conducting utilization review pursuant to this article is in
15-21 violation of [a utilization review agent has violated or is
15-22 violating] this article or applicable regulations, the commissioner
15-23 shall notify the utilization review agent, health maintenance
15-24 organization, insurer, or other person or entity of the alleged
15-25 violation and may compel the production of any and all documents or
15-26 other information as necessary in order to determine whether or not
15-27 such violation has taken place [provided by this code].
16-1 (b) The commissioner may initiate [the] proceedings under
16-2 this section [after the 30th day after the date the commissioner
16-3 notifies the agent as required by Subsection (a) of this section].
16-4 (d) If [after notice and hearing] the commissioner
16-5 determines that the utilization review agent, health maintenance
16-6 organization, insurer, or other person or entity conducting
16-7 utilization review under this article has violated or is violating
16-8 any provision of this article, the commissioner may:
16-9 (1) impose sanctions under Section 7, Article 1.10 of
16-10 this code; [or]
16-11 (2) issue a cease and desist order under Article 1.10A
16-12 of this code; or
16-13 (3) assess administrative penalties under Article
16-14 1.10E of this code.
16-15 SECTION 9. Section 13, Article 21.58A, Insurance Code, is
16-16 amended to read as follows:
16-17 Sec. 13. AUTHORITY TO ADOPT RULES. The commissioner may
16-18 [board shall have the authority to] adopt rules [and regulations]
16-19 to implement the provisions of this article. The commissioner
16-20 [board] shall appoint an [11-member] advisory committee to advise
16-21 the commissioner [board] in developing rules [and regulations] to
16-22 administer this article as authorized by Section 2001.031,
16-23 Government Code. The committee's deliberations shall be subject to
16-24 the open meetings law. The committee shall include the public
16-25 counsel and one representative for each of the following:
16-26 insurance companies, health maintenance organizations, group
16-27 hospital service corporations, utilization review agents,
17-1 employers, physicians, dentists, hospitals, registered nurses, and
17-2 other health care providers.
17-3 SECTION 10. Section 14, Article 21.58A, Insurance Code, is
17-4 amended by amending Subsections (e), (g), and (h) and adding
17-5 Subsection (j) to read as follows:
17-6 (e) This article shall not apply to the terms or benefits of
17-7 employee welfare benefit plans as defined in Section 3(1) [31(I)]
17-8 of the Employee Retirement Income Security Act of 1974 (29 U.S.C.
17-9 Section 1002(1) [1002]).
17-10 (g) A health maintenance organization is not subject to this
17-11 article except as expressly provided in this subsection and
17-12 Subsection (i) of this section. If such health maintenance
17-13 organization performs utilization review as defined herein, it
17-14 shall, as a condition of licensure:
17-15 (1) comply with Sections 1, 2, 4, 5, 6, 7, 8, 9, 11,
17-16 12, 13, and 14 [4(b), (c), (e), (f), (h), (i), and (l)] of this
17-17 article, and the commissioner [board] shall promulgate rules for
17-18 appropriate verification and enforcement of compliance. However,
17-19 nothing in this article shall be construed to prohibit or limit the
17-20 distribution of a proportion of the savings from the reduction or
17-21 elimination of unnecessary medical services, treatment, supplies,
17-22 confinements, or days of confinement in a health care facility
17-23 through profit sharing, bonus, or withhold arrangements to
17-24 participating physicians or participating health care providers for
17-25 rendering health care services to enrollees; and
17-26 (2) [establish and maintain a system for:]
17-27 [(A) handling and responding to complaints by
18-1 enrollees, patients, or health care providers;]
18-2 [(B) providing health care providers with notice
18-3 of medical necessity or program requirements that have not been
18-4 met, including a reasonable opportunity to discuss the plan of
18-5 treatment and clinical basis for a utilization review determination
18-6 with a physician; and]
18-7 [(C) providing the enrollee, patient, and health
18-8 care provider an opportunity to appeal the determination; and]
18-9 [(3)] submit to assessment of maintenance taxes under
18-10 Article 20A.33, Texas Health Maintenance Organization Act (Article
18-11 20A.33, Vernon's Texas Insurance Code), to cover the costs of
18-12 administering compliance of health maintenance organizations under
18-13 this section.
18-14 (h) An insurer which delivers or issues for delivery a
18-15 health insurance policy in Texas and is subject to this code is not
18-16 subject to this article except as expressly provided in this
18-17 subsection and Subsection (i) of this section. If an insurer
18-18 performs utilization review as defined herein it shall, as a
18-19 condition of licensure, comply with Sections 1, 2, 4, 5, 6, 7, 8,
18-20 9, 11, 12, 13, and 14 [4 through 8] of this article, and the
18-21 commissioner [board] shall promulgate rules for appropriate
18-22 verification and enforcement of compliance. Such insurers shall be
18-23 subject to assessment of maintenance tax under Article 4.17 of this
18-24 code to cover the costs of administering compliance of insurers
18-25 under this section.
18-26 (j) A specialty utilization review agent is not subject to
18-27 Section 4(b), (c), (h), or (k) or Section 6(b)(3) of this article.
19-1 For purposes of this subsection, a specialty utilization review
19-2 agent is a utilization review agent who conducts utilization review
19-3 for specialty health care services, including dentistry,
19-4 chiropractic, or physical therapy. A specialty utilization review
19-5 agent shall comply with the following requirements:
19-6 (1) the utilization review plan, including
19-7 reconsideration and appeal requirements, shall be reviewed by a
19-8 health care provider of the appropriate specialty and conducted in
19-9 accordance with standards developed with input from a health care
19-10 provider of the appropriate specialty;
19-11 (2) personnel employed by or under contract with a
19-12 specialty utilization review agent to perform utilization review
19-13 shall be appropriately trained and qualified; personnel who obtain
19-14 information directly from the physician or health care provider,
19-15 either orally or in writing, shall be nurses, physician assistants,
19-16 or other health care providers of the same specialty as the
19-17 utilization review agent and who are licensed or otherwise
19-18 authorized to provide the specialty health care service by a state
19-19 licensing agency in the United States, except that this provision
19-20 does not require those qualifications for personnel who perform
19-21 solely clerical or administrative tasks;
19-22 (3) utilization review conducted by a specialty
19-23 utilization review agent shall be conducted under the direction of
19-24 a health care provider of the same specialty and shall be licensed
19-25 or otherwise authorized to provide the specialty health care
19-26 service by a state licensing agency in the United States;
19-27 (4) subject to the notice requirements of Section 5 of
20-1 this article, in any instance where the specialty utilization
20-2 review agent questions the medical necessity or appropriateness of
20-3 health care services, the health care provider who ordered the
20-4 services shall, before the issuance of an adverse determination, be
20-5 afforded a reasonable opportunity to discuss the plan of treatment
20-6 for the patient and the clinical basis for the decision of the
20-7 utilization review agent with a health care provider of the same
20-8 specialty as the utilization review agent; and
20-9 (5) appeal decisions shall be made by a physician or
20-10 health care provider in the same or a similar specialty as
20-11 typically manages the medical, dental, or specialty condition,
20-12 procedure, or treatment under discussion for review of the adverse
20-13 determination.
20-14 SECTION 11. This Act takes effect September 1, 1997, and
20-15 applies to an act of utilization review that is performed on or
20-16 after that date. An act of utilization review that is performed
20-17 before that date is governed by the law in effect on the date the
20-18 act was performed, and the former law is continued in effect for
20-19 that purpose.
20-20 SECTION 12. The importance of this legislation and the
20-21 crowded condition of the calendars in both houses create an
20-22 emergency and an imperative public necessity that the
20-23 constitutional rule requiring bills to be read on three several
20-24 days in each house be suspended, and this rule is hereby suspended.