SRC-MWN S.B. 425 77(R)   BILL ANALYSIS


Senate Research Center   S.B. 425
77R3822 MXM-FBy: Shapleigh
Business & Commerce
3/13/2001
As Filed


DIGEST AND PURPOSE 

Currently, physicians who perform health insurance utilization reviews for
the people of Texas are not required to hold a medical license from the
state of Texas. A physician residing in a state other than Texas may not be
aware of conditions affecting health-care services unique to this state.
Further, outof-state physicians who perform utilization review on Texas
residents are not accountable to the Texas Board of Medical Examiners for
the decisions they make. As proposed, S.B. 425 requires that physicians
performing health insurance utilization reviews for the people of Texas be
required to hold a medical license in this state. S.B. 425 also eases the
process by which a health care provider may appeal a decision made by the
physician performing the utilization review. 

RULEMAKING AUTHORITY

This bill does not expressly grant any additional rulemaking authority to a
state officer, institution, or agency. 

SECTION BY SECTION ANALYSIS

SECTION 1. Amends Section 4(h), Article 21.58A, Insurance Code, to require
utilization review conducted by a utilization review agent to be under the
direction of a physician licensed to practice medicine in this state,
rather than by a state licensing agency in the United States. 

SECTION 2. Amends Section 6(b), Article 21.58A, Insurance Code, to require
the procedures for appeals to be reasonable and to include a provision that
appeal decisions be made by a physician licensed to practice medicine in
this state, provided that, if the appeal is denied and within 10 working
days the health care provider sets forth orally or in writing good cause
for having a particular type of a specialty provider review the case, the
denial is required to be reviewed by a health care provider licensed in
this state for the same or a similar specialty as typically manages the
medical or dental condition, procedure, or treatment under discussion for
review of the adverse determination, and that specialty review is required
to be completed within 15 working days of receipt of the request. Makes a
conforming change. 

SECTION 3. Effective date: upon passage or September 1, 2001.