R E S O L U T I O N
1-1 BE IT RESOLVED by the House of Representatives of the State
1-2 of Texas, 77th Legislature, Regular Session, 2001, That House Rule
1-3 13, Section 9(a), be suspended in part as provided by House Rule
1-4 13, Section 9(f), to enable the conference committee appointed to
1-5 resolve the differences on House Bill No. 1862, relating to the
1-6 regulation and prompt payment of health care providers under
1-7 certain health benefit plans and providing penalties, to consider
1-8 and take action on the following matters:
1-9 1. House Rule 13, Section 9(a)(1), is suspended to permit
1-10 the committee to change text that is not in disagreement in amended
1-11 Section 3A(b), Article 3.70-3C, Insurance Code, as added by Chapter
1-12 1024, Acts of the 75th Legislature, Regular Session, 1997, so that
1-13 the subsection reads as follows:
1-14 (b) A physician or [preferred] provider must submit a claim
1-15 to an insurer not later than the 95th day after the date the
1-16 physician or provider provides the medical care or health care
1-17 services for which the claim is made. An insurer shall accept as
1-18 proof of timely filing a claim filed in compliance with Subsection
1-19 (c) of this section or information from another insurer showing
1-20 that the physician or provider submitted the claim to the insurer
1-21 in compliance with Subsection (c) of this section. If a physician
1-22 or provider fails to submit a claim in compliance with this
1-23 subsection, the physician or provider forfeits the right to payment
1-24 unless the failure to submit the claim in compliance with this
2-1 subsection is a result of a catastrophic event that substantially
2-2 interferes with the normal business operations of the physician or
2-3 provider. The period for submitting a claim under this subsection
2-4 may be extended by contract. A physician or provider may not
2-5 submit a duplicate claim for payment before the 46th day after the
2-6 date the original claim was submitted. The commissioner shall
2-7 adopt rules under which an insurer may determine whether a claim is
2-8 a duplicate claim [for medical care or health care services under a
2-9 health insurance policy may obtain acknowledgment of receipt of a
2-10 claim for medical care or health care services under a health care
2-11 plan by submitting the claim by United States mail, return receipt
2-12 requested. An insurer or the contracted clearinghouse of an
2-13 insurer that receives a claim electronically shall acknowledge
2-14 receipt of the claim by an electronic transmission to the preferred
2-15 provider and is not required to acknowledge receipt of the claim by
2-16 the insurer in writing].
2-17 Explanation: This change is necessary to prevent a physician
2-18 or provider from forfeiting payment of a claim if a catastrophic
2-19 event prevents the physician or provider from submitting the claim
2-20 in the required time.
2-21 2. House Rule 13, Section 9(a)(1), is suspended to permit
2-22 the committee to change text that is not in disagreement in added
2-23 Section 3A(d), Article 3.70-3C, Insurance Code, so that the
2-24 subsection reads as follows:
2-25 (d) If a claim for medical care or health care services
2-26 provided to a patient is mailed, the claim is presumed to have been
2-27 received by the insurer on the third day after the date the claim
3-1 is mailed or, if the claim is mailed using overnight service or
3-2 return receipt requested, on the date the delivery receipt is
3-3 signed. If the claim is submitted electronically, the claim is
3-4 presumed to have been received on the date of the electronic
3-5 verification of receipt by the insurer or the insurer's
3-6 clearinghouse. If the insurer or the insurer's clearinghouse does
3-7 not provide a confirmation within 24 hours of submission by the
3-8 physician or provider, the physician's or provider's clearinghouse
3-9 shall provide the confirmation. The physician's or provider's
3-10 clearinghouse must be able to verify that the filing contained the
3-11 correct payor identification of the entity to receive the filing.
3-12 If the claim is faxed, the claim is presumed to have been received
3-13 on the date of the transmission acknowledgment. If the claim is
3-14 hand delivered, the claim is presumed to have been received on the
3-15 date the delivery receipt is signed. The commissioner shall
3-16 promulgate a form to be submitted by the physician or provider that
3-17 easily identifies all claims included in each filing and that can
3-18 be used by a physician or provider as the physician's or provider's
3-19 log.
3-20 Explanation: This change is necessary to require that a
3-21 physician's or provider's clearinghouse be able to verify that a
3-22 filed claim contains the correct "payor identification" of the
3-23 entity to receive the filing, rather than the "correct address" of
3-24 the entity.
3-25 3. House Rule 13, Sections 9(a)(1) and (2), is suspended to
3-26 permit the committee to change and omit text that is not in
3-27 disagreement in added Section 3A(g), Article 3.70-3C, Insurance
4-1 Code, so that the subsection reads as follows:
4-2 (g) An insurer that determines under Subsection (e) of this
4-3 section that a claim is eligible for payment and does not pay the
4-4 claim on or before the 45th day after the date the insurer receives
4-5 a clean claim shall pay the physician or provider making the claim
4-6 the lesser of the full amount of billed charges submitted on the
4-7 claim and interest on the billed charges at a rate of 15 percent
4-8 annually or two times the contracted rate and interest on that
4-9 amount at a rate of 15 percent annually. If the provider submits
4-10 the claim using a form described by Section 3B(a) of this article,
4-11 billed charges shall be established under a fee schedule provided
4-12 by the preferred provider to the insurer on or before the 30th day
4-13 after the date the physician or provider enters into a preferred
4-14 provider contract with the insurer. The preferred provider may
4-15 modify the fee schedule if the provider notifies the insurer of the
4-16 modification on or before the 90th day before the date the
4-17 modification takes effect.
4-18 Explanation: This change is necessary to omit language
4-19 relating to payment of certain claims and change the consequences
4-20 of failing to pay certain claims as required.
4-21 4. House Rule 13, Section 9(a)(1), is suspended to permit
4-22 the committee to change text that is not in disagreement in added
4-23 Section 3B(a), Article 3.70-3C, Insurance Code, to add the phrase
4-24 "in the manner prescribed".
4-25 Explanation: This change is necessary to specify that for a
4-26 claim by certain physicians or providers to be a "clean claim"
4-27 information must be entered into the required form "in the manner
5-1 prescribed".
5-2 5. House Rule 13, Section 9(a)(1), is suspended to allow the
5-3 committee to change text that is not in disagreement in amended
5-4 Section 18B(b), Texas Health Maintenance Organization Act (Article
5-5 20A.18B, Vernon's Texas Insurance Code), so that the subsection
5-6 reads as follows:
5-7 (b) A physician or provider must submit a claim under this
5-8 section to a health maintenance organization not later than the
5-9 95th day after the date the physician or provider provides the
5-10 medical care or health care services for which the claim is made.
5-11 A health maintenance organization shall accept as proof of timely
5-12 filing a claim filed in compliance with Subsection (c) of this
5-13 section or information from another health maintenance organization
5-14 showing that the physician or provider submitted the claim to the
5-15 health maintenance organization in compliance with Subsection (c)
5-16 of this section. If a physician or provider fails to submit a
5-17 claim in compliance with this subsection, the physician or provider
5-18 forfeits the right to payment unless the failure to submit the
5-19 claim in compliance with this subsection is a result of a
5-20 catastrophic event that substantially interferes with the normal
5-21 business operations of the physician or provider. The period for
5-22 submitting a claim under this subsection may be extended by
5-23 contract. A physician or provider may not submit a duplicate claim
5-24 for payment before the 46th day after the date the original claim
5-25 was submitted. The commissioner shall adopt rules under which a
5-26 health maintenance organization may determine whether a claim is a
5-27 duplicate claim. [A physician or provider for medical care or
6-1 health care services under a health care plan may obtain
6-2 acknowledgment of receipt of a claim for medical care or health
6-3 care services under a health care plan by submitting the claim by
6-4 United States mail, return receipt requested. A health maintenance
6-5 organization or the contracted clearinghouse of the health
6-6 maintenance organization that receives a claim electronically shall
6-7 acknowledge receipt of the claim by an electronic transmission to
6-8 the physician or provider and is not required to acknowledge
6-9 receipt of the claim by the health maintenance organization in
6-10 writing.]
6-11 Explanation: This change is necessary to prevent a physician
6-12 or provider from forfeiting payment of a claim if a catastrophic
6-13 event prevents the physician or provider from submitting the claim
6-14 in the required time.
6-15 6. House Rule 13, Section 9(a)(1), is suspended to allow the
6-16 committee to change text that is not in disagreement in added
6-17 Section 18B(d), Texas Health Maintenance Organization Act (Article
6-18 20A.18B, Vernon's Texas Insurance Code), so that the subsection
6-19 reads as follows:
6-20 (d) If a claim for medical care or health care services
6-21 provided to a patient is mailed, the claim is presumed to have been
6-22 received by the health maintenance organization on the third day
6-23 after the date the claim is mailed or, if the claim is mailed using
6-24 overnight service or return receipt requested, on the date the
6-25 delivery receipt is signed. If the claim is submitted
6-26 electronically, the claim is presumed to have been received on the
6-27 date of the electronic verification of receipt by the health
7-1 maintenance organization or the health maintenance organization's
7-2 clearinghouse. If the health maintenance organization or the
7-3 health maintenance organization's clearinghouse does not provide a
7-4 confirmation within 24 hours of submission by the physician or
7-5 provider, the physician's or provider's clearinghouse shall provide
7-6 the confirmation. The physician's or provider's clearinghouse must
7-7 be able to verify that the filing contained the correct payor
7-8 identification of the entity to receive the filing. If the claim
7-9 is faxed, the claim is presumed to have been received on the date
7-10 of the transmission acknowledgment. If the claim is hand
7-11 delivered, the claim is presumed to have been received on the date
7-12 the delivery receipt is signed. The commissioner shall promulgate
7-13 a form to be submitted by the physician or provider which easily
7-14 identifies all claims included in each filing which can be utilized
7-15 by the physician or provider as their log.
7-16 Explanation: This change is necessary to require that a
7-17 physician's or provider's clearinghouse be able to verify that a
7-18 filed claim contains the correct "payor identification" of the
7-19 entity to receive the filing, rather than the "correct address" of
7-20 the entity.
7-21 7. House Rule 13, Sections 9(a)(1) and (2), is suspended to
7-22 allow the committee to change and omit text that is not in
7-23 disagreement in added Section 18B(g), Texas Health Maintenance
7-24 Organization Act (Article 20A.18B, Vernon's Texas Insurance Code),
7-25 so that the subsection reads as follows:
7-26 (g) A health maintenance organization that determines under
7-27 Subsection (e) of this section that a claim is eligible for payment
8-1 and does not pay the claim on or before the 45th day after the date
8-2 the health maintenance organization receives a clean claim shall
8-3 pay the physician or provider making the claim the lesser of the
8-4 full amount of billed charges submitted on the claim and interest
8-5 on the billed charges at a rate of 15 percent annually or two times
8-6 the contracted rate and interest on that amount at a rate of 15
8-7 percent annually. If the physician or provider submits the claim
8-8 using a form described by Section 18D(a) of this Act, billed
8-9 charges shall be established under a fee schedule provided by the
8-10 physician or provider to the health maintenance organization on or
8-11 before the 30th day after the date the physician or provider enters
8-12 into the contract with the health maintenance organization. The
8-13 physician or provider may modify the fee schedule if the physician
8-14 or provider notifies the health maintenance organization of the
8-15 modification on or before the 90th day before the date the
8-16 modification takes effect.
8-17 Explanation: This change is necessary to omit language
8-18 relating to payment of certain claims and change the consequences
8-19 of failing to pay certain claims as required.
8-20 8. House Rule 13, Section 9(a)(1), is suspended to allow the
8-21 committee to change text that is not in disagreement in added
8-22 Section 18D(a), Texas Health Maintenance Organization Act, to add
8-23 the phrase "in the manner prescribed".
8-24 Explanation: This change is necessary to specify that for a
8-25 claim by certain physicians or providers to be a "clean claim"
8-26 information must be entered into the required form "in the manner
8-27 prescribed".
9-1 9. House Rule 13, Section 9(a)(1), is suspended to allow the
9-2 committee to change text that is not in disagreement in added
9-3 Section 18H(c), Texas Health Maintenance Organization Act, to
9-4 substitute the phrase "health maintenance organization" for
9-5 "insurer".
9-6 Explanation: This change is necessary to make a technical
9-7 correction that changes "insurer" to "health maintenance
9-8 organization".
9-9 10. House Rule 13, Section 9(a)(1), is suspended to allow
9-10 the committee to change text that is not in disagreement in added
9-11 Section 18I, Texas Health Maintenance Organization Act, to change
9-12 the term "preauthorization" to "verification".
9-13 Explanation: This change is necessary to apply the
9-14 provisions of the Texas Health Maintenance Organization Act
9-15 relating to "verification" of certain services, rather than
9-16 provisions relating to "preauthorization" of those services, to
9-17 certain physicians or providers.
9-18 11. House Rule 13, Section 9(a)(4), is suspended to allow
9-19 the committee to add a new section to the bill to read as follows:
9-20 SECTION 8. (a) Section 3, Article 21.53Q, Insurance Code, as
9-21 added by House Bill 1676, Acts of the 77th Legislature, Regular
9-22 Session, 2001, is amended to read as follows:
9-23 Sec. 3. TRAINING FOR CERTAIN PERSONNEL REQUIRED. (a) In
9-24 this section, "preauthorization" means a determination by [the
9-25 provision of a reliable representation to a physician or health
9-26 care provider of whether] the issuer of a health benefit plan that
9-27 the [will pay the physician or provider for proposed] medical or
10-1 health care services proposed to be provided [if the physician or
10-2 provider renders those services] to a [the] patient are medically
10-3 necessary and appropriate [for whom the services are proposed].
10-4 The term includes precertification, certification, recertification,
10-5 or any other activity that involves providing a reliable
10-6 representation by the issuer of a health benefit plan to a
10-7 physician or health care provider.
10-8 (b) The commissioner by rule shall require the issuer of a
10-9 health benefit plan to provide adequate training to appropriate
10-10 personnel responsible for preauthorization of coverage, if required
10-11 under the plan, or utilization review under the plan to prevent
10-12 wrongful denial of coverage required under this article and to
10-13 avoid confusion of medical benefits with mental health benefits.
10-14 (b) This section takes effect only if House Bill 1676, Acts
10-15 of the 77th Legislature, Regular Session, 2001, becomes law. If
10-16 House Bill 1676 does not become law, this section has no effect.
10-17 Explanation: This change is necessary to conform the
10-18 definition of "preauthorization" in Section 3, Article 21.53Q,
10-19 Insurance Code, to the definitions of "preauthorization" in House
10-20 Bill 1862 and clarify the preauthorization personnel to which the
10-21 training requirement in that section applies.
Eiland
_______________________________
Speaker of the House
I certify that H.R. No. 1398 was adopted by the House on May
27, 2001, by a non-record vote.
_______________________________
Chief Clerk of the House