1-1 By: Smithee (Senate Sponsor - Sibley) H.B. No. 3016
1-2 (In the Senate - Received from the House May 13, 1999;
1-3 May 14, 1999, read first time and referred to Committee on Economic
1-4 Development; May 14, 1999, reported favorably by the following
1-5 vote: Yeas 4, Nays 0; May 14, 1999, sent to printer.)
1-6 A BILL TO BE ENTITLED
1-7 AN ACT
1-8 relating to health care utilization review agents.
1-9 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-10 SECTION 1. Sections 5(a) and (c), Article 21.58A, Insurance
1-11 Code, are amended to read as follows:
1-12 (a) A utilization review agent shall notify the enrollee
1-13 or[,] a person acting on behalf of the enrollee and[, or] the
1-14 enrollee's provider of record of a determination made in a
1-15 utilization review.
1-16 (c) In the event of an adverse determination, the
1-17 notification by the utilization review agent must include:
1-18 (1) the principal reasons for the adverse
1-19 determination;
1-20 (2) the clinical basis for the adverse determination;
1-21 (3) a description or the source of the screening
1-22 criteria that were utilized as guidelines in making the
1-23 determination; and
1-24 (4) a description of the procedure for the complaint
1-25 and appeal process, including:
1-26 (A) notification to the enrollee of the
1-27 enrollee's right to appeal an adverse determination to an
1-28 independent review organization;
1-29 (B) notification to the enrollee of the
1-30 procedures for appealing an adverse determination to an independent
1-31 review organization; and
1-32 (C) notification to an enrollee who has a
1-33 life-threatening condition of the enrollee's right to an immediate
1-34 review by an independent review organization and the procedures to
1-35 obtain that review.
1-36 SECTION 2. Section 6(a), Article 21.58A, Insurance Code, is
1-37 amended to read as follows:
1-38 (a) A utilization review agent shall maintain and make
1-39 available a written description of appeal procedures involving an
1-40 adverse determination. For the purposes of this section, a
1-41 complaint filed concerning dissatisfaction or disagreement with an
1-42 adverse determination constitutes an appeal of that adverse
1-43 determination.
1-44 SECTION 3. Section 6(b), Article 21.58A, Insurance Code, as
1-45 amended by Chapters 163 and 1025, Acts of the 75th Legislature,
1-46 Regular Session, 1997, is amended and reenacted to read as follows:
1-47 (b) The procedures for appeals must [shall] be reasonable
1-48 and must [shall] include the following:
1-49 (1) a provision that an enrollee, a person acting on
1-50 behalf of the enrollee, or the enrollee's physician or health care
1-51 provider may appeal the adverse determination orally or in writing;
1-52 (2) a provision that, within five working days from
1-53 receipt of the appeal, the utilization review agent shall send to
1-54 the appealing party a letter acknowledging the date of the
1-55 utilization review agent's receipt of the appeal [and include a
1-56 reasonable list of documents needed to be submitted by the
1-57 appealing party to the utilization review agent for the appeal].
1-58 The [Such] letter must also include the provisions listed in this
1-59 subsection and a list of the documents that the appealing party
1-60 must submit for review by the utilization review agent. When the
1-61 utilization review agent receives an oral appeal of adverse
1-62 determination, the utilization review agent shall send a one-page
1-63 appeal form to the appealing party;
1-64 (3) a provision that appeal decisions shall be made by
2-1 a physician, provided that, if the appeal is denied and within 10
2-2 working days the health care provider sets forth in writing good
2-3 cause for having a particular type of a specialty provider review
2-4 the case, the denial shall be reviewed by a health care provider in
2-5 the same or similar specialty as typically manages the medical
2-6 or[,] dental[, or specialty] condition, procedure, or treatment
2-7 under discussion for review of the adverse determination, and that
2-8 [such] specialty review shall be completed within 15 working days
2-9 of receipt of the request;
2-10 (4) in addition to the written appeal, a method for an
2-11 expedited appeal procedure for emergency care denials [, denials of
2-12 care for life-threatening conditions,] and denials of continued
2-13 stays for hospitalized patients. That [Such] procedure must
2-14 [shall] include a review by a health care provider who has not
2-15 previously reviewed the case and who is of the same or a similar
2-16 specialty as typically manages the medical condition, procedure, or
2-17 treatment under review. The time frame in which the [such] appeal
2-18 must be completed shall be based on the medical or dental immediacy
2-19 of the condition, procedure, or treatment, but may not [in no
2-20 event] exceed one working day from the date all information
2-21 necessary to complete the appeal is received;
2-22 (5) a provision that after the utilization review
2-23 agent has sought review of the appeal of the adverse determination,
2-24 the utilization review agent shall issue a response letter to the
2-25 patient or [,] a person acting on behalf of the patient, and [or]
2-26 the patient's physician or health care provider, explaining the
2-27 resolution of the appeal[. Such letter shall include a statement
2-28 of the specific medical, dental, or contractual reasons for the
2-29 resolution, the clinical basis for such decision, and the
2-30 specialization of any physician or other provider consulted]; and
2-31 (6) [(5)] written notification to the appealing party
2-32 of the determination of the appeal, as soon as practical, but in no
2-33 case later than the 30th calendar day after the date the
2-34 utilization agent receives the appeal. If the appeal is denied,
2-35 the written notification shall include a clear and concise
2-36 statement of:
2-37 (A) the clinical basis for the appeal's denial;
2-38 (B) the specialty of the physician or other
2-39 health care provider making the denial; and
2-40 (C) notice of the appealing party's right to
2-41 seek review of the denial by an independent review organization
2-42 under Section 6A of this article and the procedures for obtaining
2-43 that review
2-44 [(6) written notification to the appealing party of
2-45 the determination of the appeal, as soon as practical, but in no
2-46 case later than 30 days after the date the utilization review agent
2-47 receives the appeal].
2-48 SECTION 4. Section 6(c), Article 21.58A, Insurance Code, is
2-49 amended to read as follows:
2-50 (c) Notwithstanding this article or any other law, in a
2-51 circumstance involving an enrollee's life-threatening condition,
2-52 the enrollee is entitled to an immediate appeal to an independent
2-53 review organization as provided by Section 6A of this article and
2-54 is not required to comply with procedures for an internal review of
2-55 the utilization review agent's adverse determination. [For
2-56 purposes of this section, "life-threatening condition" means a
2-57 disease or other medical condition with respect to which death is
2-58 probable unless the course of the disease or condition is
2-59 interrupted.]
2-60 SECTION 5. This Act takes effect September 1, 1999.
2-61 SECTION 6. The importance of this legislation and the
2-62 crowded condition of the calendars in both houses create an
2-63 emergency and an imperative public necessity that the
2-64 constitutional rule requiring bills to be read on three several
2-65 days in each house be suspended, and this rule is hereby suspended.
2-66 * * * * *