By Harris S.B. No. 594 77R5897 PB-F A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to retrospective reviews of health care services by 1-3 utilization review agents. 1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-5 SECTION 1. Section 2(20), Article 21.58A, Insurance Code, is 1-6 amended to read as follows: 1-7 (20) "Utilization review" means a system for 1-8 prospective, retrospective, or concurrent review of the medical 1-9 necessity and appropriateness of health care services provided, 1-10 being provided, or proposed to be provided to an individual within 1-11 this state. Utilization review shall not include elective requests 1-12 for clarification of coverage. 1-13 SECTION 2. Section 4, Article 21.58A, Insurance Code, is 1-14 amended by adding Subsection (p) to read as follows: 1-15 (p) A utilization review agent may not, through a 1-16 retrospective review, reduce or deny payment for health care 1-17 services or reduce or deny the number of days of inpatient care for 1-18 which a health insurance policy or health benefit plan provides 1-19 benefits if the health care services or inpatient days received by 1-20 the enrollee were preauthorized by the payor under the health 1-21 insurance policy or health benefit plan. This subsection does not 1-22 apply if: 1-23 (1) the enrollee's coverage was canceled for fraud, 1-24 misrepresentation, or nonpayment of premiums; or 2-1 (2) the preauthorization was based on a material 2-2 omission or misrepresentation made by the treating health care 2-3 provider regarding the enrollee's health condition. 2-4 SECTION 3. Section 11, Article 21.58A, Insurance Code, is 2-5 repealed. 2-6 SECTION 4. The change in law made by Article 21.58A, 2-7 Insurance Code, as amended by this Act, applies only to a 2-8 retrospective review performed by a utilization review agent on or 2-9 after the effective date of this Act. A retrospective review 2-10 performed by a utilization review agent before the effective date 2-11 of this Act is governed by the law as it existed immediately before 2-12 that date, and that law is continued in effect for this purpose. 2-13 SECTION 5. This Act takes effect September 1, 2001.