By Janek, Christian, Naishtat, Culberson H.B. No. 610
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to health care providers under certain health benefit
1-3 plans.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. The Texas Health Maintenance Organization Act
1-6 (Chapter 20A, Vernon's Texas Insurance Code) is amended by adding
1-7 Section 18B to read as follows:
1-8 Sec. 18B. PROMPT PAYMENT OF PHYSICIAN AND PROVIDERS. (a)
1-9 In this section, "clean claim" means a completed claim, as
1-10 determined under Texas Department of Insurance rules, submitted by
1-11 a physician or provider for medical care or health care services
1-12 under a health care plan.
1-13 (b) A physician or provider for medical care or health care
1-14 services under a health care plan may obtain acknowledgment of
1-15 receipt of a claim for medical care or health care services under a
1-16 health care plan by submitting the claim by United States mail,
1-17 return receipt requested. A health maintenance organization that
1-18 receives a claim electronically and that confirms receipt of the
1-19 claim electronically is not required to acknowledge receipt of the
1-20 claim in writing.
1-21 (c) Not later than the 60th day after the date that the
1-22 health maintenance organization receives a clean claim from a
1-23 physician or provider, the health maintenance organization shall:
1-24 (1) pay the total amount of the claim in accordance
2-1 with the contract between the physician or provider and the health
2-2 maintenance organization;
2-3 (2) pay the portion of the claim that is not in
2-4 dispute and notify the physician or provider in writing why the
2-5 remaining portion of the claim will not be paid; or
2-6 (3) notify the physician or provider in writing why
2-7 the claim will not be paid.
2-8 (d) If a prescription benefit claim is electronically
2-9 adjudicated, and the health maintenance organization or its
2-10 designated agent authorizes treatment, the claim must be paid not
2-11 later than the 14th day after the treatment is authorized.
2-12 (e) If the health maintenance organization acknowledges
2-13 coverage of an enrollee under the health care plan but intends to
2-14 audit the physician or provider claim, the health maintenance
2-15 organization shall pay at least 85 percent of the charges submitted
2-16 at the contracted rate on the claim not later than the 60th day
2-17 after the date that the health maintenance organization receives
2-18 the clean claim from the physician or provider. Following
2-19 completion of the audit, any additional payment due a physician or
2-20 provider or any refund due the health maintenance organization
2-21 shall be made not later than the 30th day after the later of the
2-22 date that:
2-23 (1) the physician or provider receives notice of the
2-24 audit results; or
2-25 (2) any appeal rights of the enrollee are exhausted.
2-26 (f) A health maintenance organization that violates
2-27 Subsection (c) or (e) of this section is liable to a physician or
3-1 provider for the full amount of charges submitted on the claim at
3-2 the contracted rate, plus any penalties imposed under the contract,
3-3 less any amount previously paid or any charge for a service that is
3-4 not covered by the health care plan.
3-5 (g) A physician or provider may recover reasonable
3-6 attorney's fees in an action to recover payment under this section.
3-7 (h) In addition to any other penalty or remedy authorized by
3-8 the Insurance Code or another insurance law of this state, a health
3-9 maintenance organization that violates Subsection (c) or (e) of
3-10 this section is subject to an administrative penalty under Article
3-11 1.10E, Insurance Code. The administrative penalty imposed under
3-12 that article may not exceed $1,000 for each day the claim remains
3-13 unpaid in violation of Subsection (c) or (e) of this section.
3-14 (i) The health maintenance organization shall provide a
3-15 participating physician or provider with copies of all applicable
3-16 utilization review policies and claim processing policies or
3-17 procedures, including required data elements and claim formats.
3-18 (j) A health maintenance organization may, by contract with
3-19 a physician or provider, add or change the data elements that must
3-20 be submitted with the physician or provider claim.
3-21 (k) Not later than the 60th day before the date of an
3-22 addition or change in the data elements that must be submitted with
3-23 a claim or any other change in a health maintenance organization's
3-24 claim processing and payment procedures, the health maintenance
3-25 organization shall provide written notice of the addition or change
3-26 to each participating physician or provider.
3-27 (l) This section does not apply to a claim made by an
4-1 anesthesiologist.
4-2 (m) This section does not apply to a capitation payment
4-3 required to be made to a physician or provider under an agreement
4-4 to provide medical care or health care services under a health care
4-5 plan.
4-6 (n) This section applies to a person with whom a health
4-7 maintenance organization contracts to obtain the services of
4-8 physicians and providers to provide health care services to health
4-9 care plan enrollees.
4-10 (o) The commissioner may adopt rules as necessary to
4-11 implement this section.
4-12 SECTION 2. Article 3.70-3C, Insurance Code, as added by
4-13 Chapter 1024, Acts of the 75th Legislature, Regular Session, 1997,
4-14 is amended by adding Section 3A to read as follows:
4-15 Sec. 3A. PROMPT PAYMENT OF PREFERRED PROVIDERS. (a) In
4-16 this section, "clean claim" means a completed claim, as determined
4-17 under department rules, submitted by a preferred provider for
4-18 medical care or health care services under a health insurance
4-19 policy.
4-20 (b) A preferred provider for medical care or health care
4-21 services under a health insurance policy may obtain acknowledgment
4-22 of receipt of a claim for medical care or health care services
4-23 under a health care plan by submitting the claim by United States
4-24 mail, return receipt requested. An insurer that receives a claim
4-25 electronically and that confirms receipt of the claim
4-26 electronically is not required to acknowledge receipt of the claim
4-27 in writing.
5-1 (c) Not later than the 60th day after the date that the
5-2 insurer receives a clean claim from a preferred provider, the
5-3 insurer shall:
5-4 (1) pay the total amount of the claim in accordance
5-5 with the contract between the preferred provider and the insurer;
5-6 (2) pay the portion of the claim that is not in
5-7 dispute and notify the preferred provider in writing why the
5-8 remaining portion of the claim will not be paid; or
5-9 (3) notify the preferred provider in writing why the
5-10 claim will not be paid.
5-11 (d) If a prescription benefit claim is electronically
5-12 adjudicated, and the preferred provider or its designated agent
5-13 authorizes treatment, the claim must be paid not later than the
5-14 14th day after the treatment is authorized.
5-15 (e) If the insurer acknowledges coverage of an insured under
5-16 the health insurance policy but intends to audit the preferred
5-17 provider claim, the insurer shall pay at least 85 percent of the
5-18 charges submitted at the contracted rate on the claim not later
5-19 than the 60th day after the date that the insurer receives the
5-20 clean claim from the preferred provider. Following completion of
5-21 the audit, any additional payment due a preferred provider or any
5-22 refund due the insurer shall be made not later than the 30th day
5-23 after the later of the date that:
5-24 (1) the preferred provider receives notice of the
5-25 audit results; or
5-26 (2) any appeal rights of the insured are exhausted.
5-27 (f) An insurer that violates Subsection (c) or (e) of this
6-1 section is liable to a preferred provider for the full amount of
6-2 charges submitted on the claim at the contracted rate, plus any
6-3 penalties imposed under the contract, less any amount previously
6-4 paid or any charge for a service that is not covered by the health
6-5 insurance policy.
6-6 (g) A preferred provider may recover reasonable attorney's
6-7 fees in an action to recover payment under this section.
6-8 (h) In addition to any other penalty or remedy authorized by
6-9 this code or another insurance law of this state, an insurer that
6-10 violates Subsection (c) or (e) of this section is subject to an
6-11 administrative penalty under Article 1.10E of this code. The
6-12 administrative penalty imposed under that article may not exceed
6-13 $1,000 for each day the claim remains unpaid in violation of
6-14 Subsection (c) or (e) of this section.
6-15 (i) The insurer shall provide a preferred provider with
6-16 copies of all applicable utilization review policies and claim
6-17 processing policies or procedures, including required data elements
6-18 and claim formats.
6-19 (j) An insurer may, by contract with a preferred provider,
6-20 add or change the data elements that must be submitted with the
6-21 preferred provider claim.
6-22 (k) Not later than the 60th day before the date of an
6-23 addition or change in the data elements that must be submitted with
6-24 a claim or any other change in an insurer's claim processing and
6-25 payment procedures, the insurer shall provide written notice of the
6-26 addition or change to each preferred provider.
6-27 (l) This section does not apply to a claim made by an
7-1 anesthesiologist.
7-2 (m) This section applies to a person with whom an insurer
7-3 contracts to obtain the services of preferred providers to provide
7-4 medical care or health care to insureds under a health insurance
7-5 policy.
7-6 (n) The commissioner of insurance may adopt rules as
7-7 necessary to implement this section.
7-8 SECTION 3. Section 5(c), Article 21.55, Insurance Code, is
7-9 amended to read as follows:
7-10 (c) This article does not apply to Chapter 20A of this code
7-11 except as provided in Section 9 of that chapter. This article does
7-12 not apply to a claim governed by Section 3A, Article 3.70-3C, of
7-13 this code.
7-14 SECTION 4. This Act takes effect September 1, 1999.
7-15 SECTION 5. The importance of this legislation and the
7-16 crowded condition of the calendars in both houses create an
7-17 emergency and an imperative public necessity that the
7-18 constitutional rule requiring bills to be read on three several
7-19 days in each house be suspended, and this rule is hereby suspended.