By Smithee H.B. No. 3016
76R6542 DB-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to health care utilization review agents.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Sections 5(a) and (c), Article 21.58A, Insurance
1-5 Code, are amended to read as follows:
1-6 (a) A utilization review agent shall notify the enrollee
1-7 or[,] a person acting on behalf of the enrollee and[, or] the
1-8 enrollee's provider of record of a determination made in a
1-9 utilization review.
1-10 (c) In the event of an adverse determination, the
1-11 notification by the utilization review agent must include:
1-12 (1) the principal reasons for the adverse
1-13 determination;
1-14 (2) the clinical basis for the adverse determination;
1-15 (3) a description or the source of the screening
1-16 criteria that were utilized as guidelines in making the
1-17 determination; and
1-18 (4) a description of the procedure for the complaint
1-19 and appeal process, including:
1-20 (A) notification to the enrollee of the
1-21 enrollee's right to appeal an adverse determination to an
1-22 independent review organization;
1-23 (B) notification to the enrollee of the
1-24 procedures for appealing an adverse determination to an independent
2-1 review organization; and
2-2 (C) notification to an enrollee who has a
2-3 life-threatening condition of the enrollee's right to an immediate
2-4 review by an independent review organization and the procedures to
2-5 obtain that review.
2-6 SECTION 2. Section 6(a), Article 21.58A, Insurance Code, is
2-7 amended to read as follows:
2-8 Sec. 6. APPEAL OF ADVERSE DETERMINATIONS OF UTILIZATION
2-9 REVIEW AGENTS. (a) A utilization review agent shall maintain and
2-10 make available a written description of appeal procedures involving
2-11 an adverse determination. For the purposes of this section, a
2-12 complaint filed concerning dissatisfaction or disagreement with an
2-13 adverse determination constitutes an appeal of that adverse
2-14 determination.
2-15 SECTION 3. Section 6(b), Article 21.58A, Insurance Code, as
2-16 amended by Chapters 163 and 1025, Acts of the 75th Legislature,
2-17 Regular Session, 1997, is amended and reenacted to read as follows:
2-18 (b) The procedures for appeals must [shall] be reasonable
2-19 and must [shall] include the following:
2-20 (1) a provision that an enrollee, a person acting on
2-21 behalf of the enrollee, or the enrollee's physician or health care
2-22 provider may appeal the adverse determination orally or in writing;
2-23 (2) a provision that, within five working days from
2-24 receipt of the appeal, the utilization review agent shall send to
2-25 the appealing party a letter acknowledging the date of the
2-26 utilization review agent's receipt of the appeal [and include a
2-27 reasonable list of documents needed to be submitted by the
3-1 appealing party to the utilization review agent for the appeal].
3-2 The [Such] letter must also include the provisions listed in this
3-3 subsection and a list of the documents that the appealing party
3-4 must submit for review by the utilization review agent. When the
3-5 utilization review agent receives an oral appeal of adverse
3-6 determination, the utilization review agent shall send a one-page
3-7 appeal form to the appealing party;
3-8 (3) a provision that appeal decisions shall be made by
3-9 a physician, provided that, if the appeal is denied and within 10
3-10 working days the health care provider sets forth in writing good
3-11 cause for having a particular type of a specialty provider review
3-12 the case, the denial shall be reviewed by a health care provider in
3-13 the same or similar specialty as typically manages the medical[,
3-14 dental, or specialty] condition, procedure, or treatment under
3-15 discussion for review of the adverse determination, and that [such]
3-16 specialty review shall be completed within 15 working days of
3-17 receipt of the request;
3-18 (4) in addition to the written appeal, a method for an
3-19 expedited appeal procedure for emergency care denials [, denials of
3-20 care for life-threatening conditions,] and denials of continued
3-21 stays for hospitalized patients. That [Such] procedure must
3-22 [shall] include a review by a health care provider who has not
3-23 previously reviewed the case and who is of the same or a similar
3-24 specialty as typically manages the medical condition, procedure, or
3-25 treatment under review. The time frame in which the [such] appeal
3-26 must be completed shall be based on the medical or dental immediacy
3-27 of the condition, procedure, or treatment, but may not [in no
4-1 event] exceed one working day from the date all information
4-2 necessary to complete the appeal is received;
4-3 (5) a provision that after the utilization review
4-4 agent has sought review of the appeal of the adverse determination,
4-5 the utilization review agent shall issue a response letter to the
4-6 patient or [,] a person acting on behalf of the patient, and [or]
4-7 the patient's physician or health care provider, explaining the
4-8 resolution of the appeal[. Such letter shall include a statement
4-9 of the specific medical, dental, or contractual reasons for the
4-10 resolution, the clinical basis for such decision, and the
4-11 specialization of any physician or other provider consulted]; [and]
4-12 (6) [(5)] written notification to the appealing party
4-13 of the determination of the appeal, as soon as practical, but in no
4-14 case later than the 30th calendar day after the date the
4-15 utilization agent receives the appeal. If the appeal is denied,
4-16 the written notification shall include a clear and concise
4-17 statement of:
4-18 (A) the clinical basis for the appeal's denial;
4-19 (B) the specialty of the physician making the
4-20 denial; and
4-21 (C) notice of the appealing party's right to
4-22 seek review of the denial by an independent review organization
4-23 under Section 6A of this article and the procedures for obtaining
4-24 that review; and
4-25 (7) a provision that the appealing party must be
4-26 provided a clear and concise statement of the clinical basis for
4-27 the adverse determination
5-1 [(6) written notification to the appealing party of
5-2 the determination of the appeal, as soon as practical, but in no
5-3 case later than 30 days after the date the utilization review agent
5-4 receives the appeal].
5-5 SECTION 4. Section 6(c), Article 21.58A, Insurance Code, is
5-6 amended to read as follows:
5-7 (c) Notwithstanding this article or any other law, in a
5-8 circumstance involving an enrollee's life-threatening condition,
5-9 the enrollee is entitled to an immediate appeal to an independent
5-10 review organization as provided by Section 6A of this article and
5-11 is not required to comply with procedures for an internal review of
5-12 the utilization review agent's adverse determination. [For
5-13 purposes of this section, "life-threatening condition" means a
5-14 disease or other medical condition with respect to which death is
5-15 probable unless the course of the disease or condition is
5-16 interrupted.]
5-17 SECTION 5. This Act takes effect September 1, 1999.
5-18 SECTION 6. The importance of this legislation and the
5-19 crowded condition of the calendars in both houses create an
5-20 emergency and an imperative public necessity that the
5-21 constitutional rule requiring bills to be read on three several
5-22 days in each house be suspended, and this rule is hereby suspended.