By Chavez H.B. No. 1090
77R3822 MXM-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the qualifications for persons who review the necessity
1-3 or appropriateness of health care services.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Section 4(h), Article 21.58A, Insurance Code, is
1-6 amended to read as follows:
1-7 (h) Utilization review conducted by a utilization review
1-8 agent shall be under the direction of a physician licensed to
1-9 practice medicine in this state [by a state licensing agency in the
1-10 United States].
1-11 SECTION 2. Section 6(b), Article 21.58A, Insurance Code, is
1-12 amended to read as follows:
1-13 (b) The procedures for appeals must be reasonable and must
1-14 include the following:
1-15 (1) a provision that an enrollee, a person acting on
1-16 behalf of the enrollee, or the enrollee's physician or health care
1-17 provider may appeal the adverse determination orally or in writing;
1-18 (2) a provision that, within five working days from
1-19 receipt of the appeal, the utilization review agent shall send to
1-20 the appealing party a letter acknowledging the date of the
1-21 utilization review agent's receipt of the appeal. The letter must
1-22 also include the provisions listed in this subsection and a list of
1-23 the documents that the appealing party must submit for review by
1-24 the utilization review agent. When the utilization review agent
2-1 receives an oral appeal of adverse determination, the utilization
2-2 review agent shall send a one-page appeal form to the appealing
2-3 party;
2-4 (3) a provision that appeal decisions shall be made by
2-5 a physician licensed to practice medicine in this state, provided
2-6 that, if the appeal is denied and within 10 working days the health
2-7 care provider sets forth orally or in writing good cause for having
2-8 a particular type of a specialty provider review the case, the
2-9 denial shall be reviewed by a health care provider licensed in this
2-10 state for [in] the same or a similar specialty as typically manages
2-11 the medical or dental condition, procedure, or treatment under
2-12 discussion for review of the adverse determination, and that
2-13 specialty review shall be completed within 15 working days of
2-14 receipt of the request;
2-15 (4) in addition to the oral or written appeal, a
2-16 method for an expedited appeal procedure for emergency care denials
2-17 and denials of continued stays for hospitalized patients. That
2-18 procedure must include a review by a health care provider who has
2-19 not previously reviewed the case and who is of the same or a
2-20 similar specialty as typically manages the medical condition,
2-21 procedure, or treatment under review. The time frame in which the
2-22 appeal must be completed shall be based on the medical or dental
2-23 immediacy of the condition, procedure, or treatment, but may not
2-24 exceed one working day from the date all information necessary to
2-25 complete the appeal is received;
2-26 (5) a provision that after the utilization review
2-27 agent has sought review of the appeal of the adverse determination,
3-1 the utilization review agent shall issue a response letter to the
3-2 patient or a person acting on behalf of the patient, and the
3-3 patient's physician or health care provider, explaining the
3-4 resolution of the appeal; and
3-5 (6) written notification to the appealing party of the
3-6 determination of the appeal, as soon as practical, but in no case
3-7 later than the 30th calendar day after the date the utilization
3-8 agent receives the appeal. If the appeal is denied, the written
3-9 notification shall include a clear and concise statement of:
3-10 (A) the clinical basis for the appeal's denial;
3-11 (B) the specialty of the physician or other
3-12 health care provider making the denial; and
3-13 (C) notice of the appealing party's right to
3-14 seek review of the denial by an independent review organization
3-15 under Section 6A of this article and the procedures for obtaining
3-16 that review.
3-17 SECTION 3. This Act takes effect immediately if it receives
3-18 a vote of two-thirds of all the members elected to each house, as
3-19 provided by Section 39, Article III, Texas Constitution. If this
3-20 Act does not receive the vote necessary for immediate effect, this
3-21 Act takes effect September 1, 2001.