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