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.