1-1 By: Van de Putte, Nelson S.B. No. 1284
1-2 (In the Senate - Filed March 7, 2001; March 12, 2001, read
1-3 first time and referred to Committee on Business and Commerce;
1-4 April 24, 2001, reported adversely, with favorable Committee
1-5 Substitute by the following vote: Yeas 7, Nays 0; April 24, 2001,
1-6 sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 1284 By: Van de Putte
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to payment by certain issuers of health benefit plans of
1-11 certain claims; providing penalties.
1-12 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-13 SECTION 1. Section 1, Article 3.70-3C, Insurance Code, as
1-14 added by Chapter 1024, Acts of the 75th Legislature, Regular
1-15 Session, 1997, is amended by adding Subdivision (14) to read as
1-16 follows:
1-17 (14) "Preauthorization" means a reliable
1-18 representation by an insurer to a physician or health care provider
1-19 that the insurer will pay the physician or health care provider for
1-20 proposed medical or health care services if the physician or health
1-21 care provider renders those services to the patient for whom the
1-22 services are proposed. The term includes precertification,
1-23 certification, re-certification, or any other term that would be a
1-24 reliable representation by an insurer to a physician or health care
1-25 provider.
1-26 SECTION 2. Section 3A, Article 3.70-3C, Insurance Code, as
1-27 added by Chapter 1024, Acts of the 75th Legislature, Regular
1-28 Session, 1997, is amended to read as follows:
1-29 Sec. 3A. PROMPT PAYMENT OF PREFERRED PROVIDERS. (a) In
1-30 this section, "clean claim" means a [completed] claim that complies
1-31 with Section 3B of this article[, as determined under department
1-32 rules, submitted by a preferred provider for medical care or health
1-33 care services under a health insurance policy].
1-34 (b) A physician or provider must submit a claim to an
1-35 insurer not later than the 95th day after the date the physician or
1-36 provider provides the medical care or health care services for
1-37 which the claim is made. An insurer shall accept as proof of
1-38 timely filing a claim filed in compliance with Subsection (c) of
1-39 this section or information from another insurer showing that the
1-40 physician or provider submitted the claim to the insurer in
1-41 compliance with Subsection (c) of this section. If a physician or
1-42 provider fails to submit a claim in compliance with this
1-43 subsection, the physician or provider forfeits the right to
1-44 payment. The period for submitting a claim under this subsection
1-45 may be extended by contract. A physician or provider may not
1-46 submit a duplicate claim for payment before the 46th day after the
1-47 date the original claim was submitted. The commissioner shall
1-48 adopt rules under which an insurer may determine whether a claim is
1-49 a duplicate claim [A preferred provider for medical care or health
1-50 care services under a health insurance policy may obtain
1-51 acknowledgment of receipt of a claim for medical care or health
1-52 care services under a health care plan by submitting the claim by
1-53 United States mail, return receipt requested. An insurer or the
1-54 contracted clearinghouse of an insurer that receives a claim
1-55 electronically shall acknowledge receipt of the claim by an
1-56 electronic transmission to the preferred provider and is not
1-57 required to acknowledge receipt of the claim by the insurer in
1-58 writing].
1-59 (c) A physician or provider shall, as appropriate:
1-60 (1) mail a claim by United States mail, first class,
1-61 or by overnight delivery service, and maintain a log of mailed
1-62 claims and include a copy of the log with the relevant mailed
1-63 claim;
1-64 (2) submit the claim electronically and maintain a log
2-1 of electronically submitted claims;
2-2 (3) fax the claim and maintain a log of all faxed
2-3 claims; or
2-4 (4) hand deliver the claim and maintain a log of all
2-5 hand-delivered claims.
2-6 (d) If a claim for medical care or health care services
2-7 under a health care plan is mailed, the claim is presumed to have
2-8 been received by the insurer on the third day after the date the
2-9 claim is mailed or, if the claim is mailed using overnight service
2-10 or return receipt requested, on the date the delivery receipt is
2-11 signed. If the claim is submitted electronically, the claim is
2-12 presumed to have been received on the date of the electronic
2-13 verification of receipt by the insurer or the insurer's
2-14 clearinghouse. If the insurer or the insurer's clearinghouse fails
2-15 to provide a confirmation within 24 hours of submission by the
2-16 physician or provider, the physician's or provider's clearinghouse
2-17 shall provide the confirmation. If the claim is faxed, the claim
2-18 is presumed to have been received on the date of the transmission
2-19 acknowledgment. If the claim is hand delivered, the claim is
2-20 presumed to have been received on the date the delivery receipt is
2-21 signed.
2-22 (e) Not later than the 45th day after the date that the
2-23 insurer receives a clean claim from a preferred provider, the
2-24 insurer shall make a determination of whether the claim is eligible
2-25 for payment and:
2-26 (1) if the insurer determines the entire claim is
2-27 eligible for payment, pay the total amount of the claim in
2-28 accordance with the contract between the preferred provider and the
2-29 insurer;
2-30 (2) if the insurer disputes a portion of the claim,
2-31 pay the portion of the claim that is not in dispute and notify the
2-32 preferred provider in writing why the remaining portion of the
2-33 claim will not be paid; or
2-34 (3) if the insurer determines that the claim is not
2-35 eligible for payment, notify the preferred provider in writing why
2-36 the claim will not be paid.
2-37 (f) Not later than the 21st day after the date an insurer
2-38 affirmatively adjudicates a pharmacy benefit claim that is
2-39 electronically submitted, the insurer shall:
2-40 (1) pay the total amount of the claim; or
2-41 (2) notify the benefit provider of the reasons for
2-42 denying payment of the claim.
2-43 (g) An insurer that makes a determination that a claim is
2-44 eligible for payment under Subsection (e) of this section and does
2-45 not pay the claim on or before the 45th day after the date the
2-46 insurer receives a clean claim:
2-47 (1) shall pay the physician or provider making the
2-48 claim the full amount of billed charges submitted on the claim,
2-49 based on the physician's or provider's charges for medical or
2-50 health care services at the time the services are provided and
2-51 interest on the billed charges at a rate of 15 percent annually;
2-52 (2) commits an unfair claim settlement practice in
2-53 violation of Article 21.21-2 of this code; and
2-54 (3) is subject to an administrative penalty under
2-55 Chapter 84 of this code.
2-56 (h) The investigation and determination of eligibility or
2-57 coverage, including any limitations or exclusions, and coordination
2-58 of other health benefit plan coverage does not extend the period
2-59 for determining whether a claim is eligible for payment under
2-60 Subsection (e) of this section [(d) If a prescription benefit claim
2-61 is electronically adjudicated and electronically paid, and the
2-62 preferred provider or its designated agent authorizes treatment,
2-63 the claim must be paid not later than the 21st day after the
2-64 treatment is authorized].
2-65 (i) Except as provided by Subsections (j), (k), (l), and (m)
2-66 of this section, if [(e) If] the insurer acknowledges coverage of
2-67 an insured under the health insurance policy but intends to audit
2-68 the preferred provider claim, the insurer shall pay the charges
2-69 submitted at 85 percent of the contracted rate on the claim not
3-1 later than the 45th day after the date that the insurer receives
3-2 the claim from the preferred provider. The insurer must complete
3-3 [Following completion of] the audit and make[,] any additional
3-4 payment due a preferred provider or any refund due the insurer
3-5 [shall be made] not later than the 90th [30th] day after the [later
3-6 of the] date the claim is received by the insurer [that:]
3-7 [(1) the preferred provider receives notice of the
3-8 audit results; or]
3-9 [(2) any appeal rights of the insured are exhausted].
3-10 (j) If an insurer needs additional information from a
3-11 treating preferred provider to determine benefits payable under the
3-12 policy, the insurer, not later than the 30th calendar day after the
3-13 date the insurer receives a clean claim, shall request in writing
3-14 that the preferred provider provide any attachment to the claim the
3-15 insurer desires in good faith for clarification of the claim. The
3-16 request must describe with specificity the clinical information
3-17 requested, provide a detailed description of the reasons for the
3-18 request, and relate only to information the insurer can demonstrate
3-19 is within the scope of the claim and specific to the claim. An
3-20 insurer may not make more than one request under this subsection in
3-21 connection with a claim.
3-22 (k) On or before the 20th day after the date a treating
3-23 preferred provider receives a request that complies with Subsection
3-24 (j) of this section, the preferred provider shall provide the
3-25 requested attachment. The period for determining whether a claim
3-26 is eligible for payment under Subsection (e) of this section is
3-27 tolled until the attachment is provided. Subsections (c) and (d)
3-28 of this section apply to an attachment provided by a preferred
3-29 provider under this subsection.
3-30 (l) If an insurer needs additional information from the
3-31 insured or a physician or provider other than the physician or
3-32 provider who submitted the claim to determine benefits payable
3-33 under the policy, the insurer shall notify the treating preferred
3-34 provider and the person from whom the information is needed not
3-35 later than the 30th calendar day after the date the insurer
3-36 receives the claim. The notice shall describe with specificity the
3-37 information requested and, if applicable, provide the name of the
3-38 physician or provider from whom the information is needed, if the
3-39 name is available to the insurer.
3-40 (m) A person from whom the information is requested under
3-41 Subsection (l) of this section shall furnish the requested
3-42 information on or before the 15th day after the date the person
3-43 receives the request. The period for determining whether a claim
3-44 is eligible for payment under Subsection (e) of this section is
3-45 tolled by the number of days, not to exceed 30 days, by which the
3-46 requested information is delinquent. An insurer that does not
3-47 receive information requested under Subsection (l) of this section
3-48 shall send a reminder notice to the treating preferred provider and
3-49 to the person from whom the information is needed every 10th day
3-50 after the date the information becomes delinquent. A treating
3-51 preferred provider may send a reminder notice to an insured or
3-52 other person from whom information is requested under Subsection
3-53 (l) of this section as the preferred provider considers necessary
3-54 to ensure a prompt response.
3-55 (n) The commissioner shall adopt rules under which an
3-56 insurer can easily identify attachments submitted by a physician or
3-57 health care provider under Subsection (k) or (m) of this section
3-58 [(f) An insurer that violates Subsection (c) or (e) of this
3-59 section is liable to a preferred provider for the full amount of
3-60 billed charges submitted on the claim or the amount payable under
3-61 the contracted penalty rate, less any amount previously paid or any
3-62 charge for a service that is not covered by the health insurance
3-63 policy].
3-64 (o) [(g)] A preferred provider may recover reasonable
3-65 attorney's fees and court costs in an action to recover payment
3-66 under this section.
3-67 (p) [(h) In addition to any other penalty or remedy
3-68 authorized by this code or another insurance law of this state, an
3-69 insurer that violates Subsection (c) or (e) of this section is
4-1 subject to an administrative penalty under Article 1.10E of this
4-2 code. The administrative penalty imposed under that article may
4-3 not exceed $1,000 for each day the claim remains unpaid in
4-4 violation of Subsection (c) or (e) of this section.]
4-5 [(i)] The insurer shall provide a preferred provider with
4-6 copies of all applicable utilization review policies and claim
4-7 processing policies or procedures, including required data elements
4-8 and claim formats.
4-9 (q) [(j) An insurer may, by contract with a preferred
4-10 provider, add or change the data elements that must be submitted
4-11 with the preferred provider claim.]
4-12 [(k) Not later than the 60th day before the date of an
4-13 addition or change in the data elements that must be submitted with
4-14 a claim or any other change in an insurer's claim processing and
4-15 payment procedures, the insurer shall provide written notice of the
4-16 addition or change to each preferred provider.]
4-17 [(l) This section does not apply to a claim made by a
4-18 preferred provider who is a member of the legislature.]
4-19 [(m)] This section applies to a person with whom an insurer
4-20 contracts to process claims or to obtain the services of preferred
4-21 providers to provide medical care or health care to insureds under
4-22 a health insurance policy.
4-23 (r) [(n)] The commissioner of insurance may adopt rules as
4-24 necessary to implement this section.
4-25 SECTION 3. Article 3.70-3C, Insurance Code, as added by
4-26 Chapter 1024, Acts of the 75th Legislature, Regular Session, 1997,
4-27 is amended by adding Sections 3B through 3J, 10, 11, and 12 to read
4-28 as follows:
4-29 Sec. 3B. ELEMENTS OF CLEAN CLAIM. (a) A claim by a
4-30 provider, other than an institutional provider, is a "clean claim"
4-31 if the claim is submitted using Health Care Financing
4-32 Administration Form 1500 or another Health Care Financing
4-33 Administration form adopted by the commissioner by rule for the
4-34 purposes of this subsection that is submitted to an insurer for
4-35 payment and that contains the information required by the
4-36 commissioner by rule for the purposes of this subsection entered
4-37 into the appropriate fields on the form.
4-38 (b) A claim by an institutional provider is a "clean claim"
4-39 if the claim is submitted using Health Care Financing
4-40 Administration Form UB-92 or another Health Care Financing
4-41 Administration form adopted by the commissioner by rule for the
4-42 purposes of this subsection that is submitted to an insurer for
4-43 payment and that contains the information required by the
4-44 commissioner by rule for the purposes of this subsection entered
4-45 into the appropriate fields on the form.
4-46 (c) An insurer may require any data element that is required
4-47 in an electronic transaction set needed to comply with federal law.
4-48 An insurer may not require a provider to provide information other
4-49 than information for a data field included on the form used for a
4-50 clean claim under Subsection (a) or (b) of this section, as
4-51 applicable.
4-52 (d) A claim submitted by a physician or provider that
4-53 includes additional fields, data elements, attachments, or other
4-54 information not required under this section is considered to be a
4-55 clean claim for the purposes of this article.
4-56 Sec. 3C. OVERPAYMENT. An insurer may recover an overpayment
4-57 to a physician or provider if:
4-58 (1) not later than the 180th day after the date the
4-59 physician or provider receives the payment, the insurer provides
4-60 written notice of the overpayment to the physician or provider that
4-61 includes the basis and specific reasons for the request for
4-62 recovery of funds; and
4-63 (2) the physician or provider does not make
4-64 arrangements for repayment of the requested funds on or before the
4-65 45th day after the date the physician or provider receives the
4-66 notice.
4-67 Sec. 3D. VERIFICATION OF COVERAGE. (a) On the request of a
4-68 physician or provider for verification of the eligibility for
4-69 payment of a particular medical care or health care service the
5-1 physician or provider proposes to provide to a particular patient,
5-2 the insurer shall inform the physician or provider whether the
5-3 service, if provided to that patient, is eligible for payment from
5-4 the insurer to the physician or provider.
5-5 (b) An insurer shall provide verification under this section
5-6 between 6 a.m. and 6 p.m. central standard time each day.
5-7 (c) Verification under this section shall be made in good
5-8 faith and without delay.
5-9 Sec. 3E. COORDINATION OF BENEFITS. (a) An insurer may
5-10 require a physician or provider to retain in the physician's or
5-11 provider's records updated information concerning other health
5-12 benefit plan coverage and to provide the information to the
5-13 insurer on the applicable form described by Section 3B of this
5-14 article. Except as provided in this subsection, an insurer may not
5-15 require a physician or provider to investigate coordination of
5-16 other health benefit plan coverage. This provision may not be
5-17 waived, voided, or nullified by contract.
5-18 (b) Coordination of other health benefit plan coverage does
5-19 not extend the period for determining whether a claim is eligible
5-20 for payment under Section 3A(e) of this article.
5-21 (c) A physician or provider who submits a claim for
5-22 particular medical or health care services to more than one health
5-23 maintenance organization or insurer shall provide written notice
5-24 on the claim submitted to each health maintenance organization or
5-25 insurer of the identity of each other health maintenance
5-26 organization or insurer with which the same claim is being filed.
5-27 (d) On receipt of notice under Subsection (c) of this
5-28 section, an insurer shall coordinate and determine the appropriate
5-29 payment for each health maintenance organization or insurer to make
5-30 to the physician or provider.
5-31 (e) If an insurer is a secondary payor and pays more than
5-32 the amount for which the insurer is legally obligated, the insurer
5-33 may recover the amount of the overpayment from the health
5-34 maintenance organization or insurer that is primarily responsible
5-35 for that amount.
5-36 (f) If the portion of the claim overpaid by the secondary
5-37 insurer was also paid by the primary health maintenance
5-38 organization or insurer, the secondary insurer may recover the
5-39 amount of overpayment under Section 3C of this article from the
5-40 physician or provider who received the payment.
5-41 (g) An insurer may share information with another health
5-42 maintenance organization or insurer to the extent necessary to
5-43 coordinate appropriate payment obligations on a specific claim.
5-44 Sec. 3F. PREAUTHORIZATION OF MEDICAL AND HEALTH CARE
5-45 SERVICES. (a) An insurer that uses a preauthorization process for
5-46 medical and health care services shall provide each participating
5-47 physician or health care provider, not later than the 10th working
5-48 day after the date a request is made, a list of medical and health
5-49 care services that require preauthorization and information
5-50 concerning the preauthorization process.
5-51 (b) If proposed medical or health care services require
5-52 preauthorization as a condition of the insurer's payment to a
5-53 physician or health care provider under a health insurance policy
5-54 or a physician or health care provider requests preauthorization of
5-55 proposed medical or health care services, the insurer shall
5-56 determine whether the medical or health care services proposed to
5-57 be provided to the insured are medically necessary and appropriate
5-58 in a manner consistent with Article 21.58A of this code.
5-59 (c) On receipt of a request from a physician or health care
5-60 provider for preauthorization of proposed medical or health care
5-61 services, the insurer shall review and issue a determination
5-62 indicating whether the proposed services are preauthorized. If the
5-63 determination requires a determination of medical necessity and
5-64 appropriateness of the proposed medical or health care services,
5-65 the determination must be made within the time frame for a
5-66 utilization review required by Section 5, Article 21.58A of this
5-67 code.
5-68 (d) If the proposed medical or health care services involve
5-69 inpatient care, the determination issued by the insurer must
6-1 specify an approved length of stay for admission into a health care
6-2 facility based on the recommendation of the patient's physician or
6-3 health care provider and the insurer's written medically acceptable
6-4 screening criteria and review procedures. The criteria and
6-5 procedures must be established, periodically evaluated, and updated
6-6 as required by Section 4(i), Article 21.58A of this code.
6-7 (e) If an insurer has preauthorized medical or health care
6-8 services, the insurer may not deny or reduce payment to the
6-9 physician or health care provider for those services unless the
6-10 physician or health care provider has materially misrepresented the
6-11 proposed medical or health care services or has substantially
6-12 failed to perform the proposed medical or health care services.
6-13 (f) This section applies to an agent or other person with
6-14 whom an insurer contracts to perform, or to whom the insurer
6-15 delegates the performance of, preauthorization of proposed medical
6-16 or health care services.
6-17 Sec. 3G. RETROSPECTIVE REVIEW. (a) An insurer that makes
6-18 an adverse determination to deny or reduce payment to a physician
6-19 or health care provider who provided medical or health care
6-20 services with a retrospective review of the medical necessity and
6-21 appropriateness of those services must conduct the retrospective
6-22 review in compliance with the standards for a utilization review
6-23 required by Sections 4(b), (c), (d), (f), (h), (i), (l), and (m),
6-24 Article 21.58A of this code.
6-25 (b) An insurer that makes an adverse determination to deny
6-26 or reduce payment to a physician or health care provider based on a
6-27 retrospective review of the medical necessity and appropriateness
6-28 of the medical or health care services shall notify the physician
6-29 or provider of the determination not later than the 45th day after
6-30 the date the insurer receives a clean claim, as defined by Section
6-31 3A of this article, from the physician or health care provider.
6-32 (c) A notice of adverse determination required by Subsection
6-33 (b) of this section must include:
6-34 (1) the principal reasons for the adverse
6-35 determination;
6-36 (2) the clinical basis for the adverse determination;
6-37 (3) a description or the source of the screening
6-38 criteria used as a guideline in making the determination; and
6-39 (4) a description of the procedure for the complaint
6-40 and appeal process, including an appeal of an adverse determination
6-41 to an independent review organization.
6-42 (d) The procedure for appeal must be reasonable and must
6-43 comply with Sections 6(b)(1), (2), (3), (5), and (6), Article
6-44 21.58A of this code.
6-45 (e) An adverse determination described by this section is
6-46 eligible for review under Section 6A, Article 21.58A of this code,
6-47 if the determination relates to:
6-48 (1) a single submitted charge of more than $650; or
6-49 (2) two or more submitted charges for the same or
6-50 similar services with a cumulative amount of more than $650.
6-51 (f) This section applies to an agent or other person with
6-52 whom an insurer contracts to perform, or to whom the insurer
6-53 delegates the performance of, a retrospective review of medical or
6-54 health care services.
6-55 Sec. 3H. AVAILABILITY OF CODING GUIDELINES. (a) A
6-56 preferred provider contract between an insurer and a physician or
6-57 provider must provide that:
6-58 (1) the physician or provider may request a copy of
6-59 the coding guidelines, including any underlying bundling, recoding,
6-60 or other payment process and fee schedules applicable to specific
6-61 procedures that the physician or provider will receive under the
6-62 contract;
6-63 (2) the insurer or the insurer's agent will provide
6-64 the guidelines not later than the 30th day after the date the
6-65 insurer receives the request;
6-66 (3) the insurer will provide notice of material
6-67 changes to the coding guidelines and fee schedules not later than
6-68 the 90th day before the date the changes take effect and will not
6-69 make retroactive revisions to the coding guidelines and fee
7-1 schedules; and
7-2 (4) the contract may be terminated by the physician or
7-3 provider on or before the 30th day after the date the physician or
7-4 provider receives information requested under this subsection
7-5 without penalty or discrimination in participation in other health
7-6 care products or plans.
7-7 (b) A physician or provider who receives information under
7-8 Subsection (a) of this section may use or disclose the information
7-9 only for the purpose of practice management, billing activities, or
7-10 other business operations. The commissioner may impose and collect
7-11 a penalty of $1,000 for each use or disclosure of the information
7-12 that violates this subsection.
7-13 Sec. 3I. DISPUTE RESOLUTION. (a) An agreement or contract
7-14 provision that requires the use of binding arbitration to resolve
7-15 future disputes in a preferred provider contract is not enforceable
7-16 if the agreement or provision is unconscionable at the time the
7-17 agreement is made. This subsection does not prohibit an insurer
7-18 from offering a dispute resolution procedure or binding arbitration
7-19 to resolve a dispute if the insurer and the physician or provider
7-20 consent to the process after the dispute arises. This subsection
7-21 may not be construed to conflict with any applicable appeal
7-22 mechanisms required by law.
7-23 (b) The provisions of this section may not be waived or
7-24 nullified by contract.
7-25 Sec. 3J. AUTHORITY OF ATTORNEY GENERAL. In addition to any
7-26 other remedy available for a violation of this article, the
7-27 attorney general may take action and seek remedies available under
7-28 Section 15, Article 21.21 of this code, and Sections 17.58, 17.60,
7-29 17.61, and 17.62, Business & Commerce Code, for a violation of
7-30 Section 3A or 7 of this article.
7-31 Sec. 10. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND HEALTH
7-32 CARE PROVIDERS. The provisions of this article relating to prompt
7-33 payment by an insurer of a physician or health care provider and to
7-34 preauthorization and retrospective review of medical or health care
7-35 services apply to a physician or health care provider who:
7-36 (1) is not a preferred provider under a preferred
7-37 provider benefit plan; and
7-38 (2) provides to an insured:
7-39 (A) emergency care; or
7-40 (B) specialty or other medical or health care
7-41 services at the request of the insurer or a preferred provider
7-42 because the services are not reasonably available from a preferred
7-43 provider.
7-44 Sec. 11. CONFLICT WITH OTHER LAW. To the extent of any
7-45 conflict between this article and Article 21.52C of this code, this
7-46 article controls.
7-47 Sec. 12. APPLICATION OF CERTAIN PROVISIONS UNDER MEDICAID.
7-48 A provision of this article may not be interpreted as requiring an
7-49 insurer, physician, or health care provider, in providing benefits
7-50 or services under the state Medicaid program, to:
7-51 (1) use billing forms or codes that are inconsistent
7-52 with those required under the state Medicaid program; or
7-53 (2) make determinations relating to medical necessity
7-54 or appropriateness or eligibility for coverage in a manner
7-55 different than that required under the state Medicaid program.
7-56 SECTION 4. Section 2, Texas Health Maintenance Organization
7-57 Act (Article 20A.02, Vernon's Texas Insurance Code), is amended by
7-58 adding Subsection (ff) to read as follows:
7-59 (ff) "Preauthorization" means a reliable
7-60 representation by a health maintenance organization to a physician
7-61 or health care provider that the health maintenance organization
7-62 will pay the physician or health care provider for proposed medical
7-63 or health care services if the physician or health care provider
7-64 renders those services to the patient for whom the services are
7-65 proposed. The term includes precertification, certification,
7-66 re-certification, or any other term that would be a reliable
7-67 representation by a health maintenance organization to a physician
7-68 or health care provider.
7-69 SECTION 5. Section 18B, Texas Health Maintenance
8-1 Organization Act (Article 20A.18B, Vernon's Texas Insurance Code),
8-2 is amended to read as follows:
8-3 Sec. 18B. PROMPT PAYMENT OF PHYSICIAN AND PROVIDERS.
8-4 (a) In this section, "clean claim" means a [completed] claim that
8-5 complies with Section 18D of this Act[, as determined under Texas
8-6 Department of Insurance rules, submitted by a physician or provider
8-7 for medical care or health care services under a health care plan].
8-8 (b) A physician or provider must submit a claim under this
8-9 section to a health maintenance organization not later than the
8-10 95th day after the date the physician or provider provides the
8-11 medical care or health care services for which the claim is made.
8-12 A health maintenance organization shall accept as proof of timely
8-13 filing a claim filed in compliance with Subsection (c) of this
8-14 section or information from another health maintenance organization
8-15 showing that the physician or provider submitted the claim to the
8-16 health maintenance organization in compliance with Subsection (c)
8-17 of this section. If a physician or provider fails to submit a
8-18 claim in compliance with this subsection, the physician or provider
8-19 forfeits the right to payment. The period for submitting a claim
8-20 under this subsection may be extended by contract. A physician or
8-21 provider may not submit a duplicate claim for payment before the
8-22 46th day after the date the original claim was submitted. The
8-23 commissioner shall adopt rules under which a health maintenance
8-24 organization may determine whether a claim is a duplicate claim [A
8-25 physician or provider for medical care or health care services
8-26 under a health care plan may obtain acknowledgment of receipt of a
8-27 claim for medical care or health care services under a health care
8-28 plan by submitting the claim by United States mail, return receipt
8-29 requested. A health maintenance organization or the contracted
8-30 clearinghouse of the health maintenance organization that receives
8-31 a claim electronically shall acknowledge receipt of the claim by an
8-32 electronic transmission to the physician or provider and is not
8-33 required to acknowledge receipt of the claim by the health
8-34 maintenance organization in writing].
8-35 (c) A physician or provider shall, as appropriate:
8-36 (1) mail a claim by United States mail, first class,
8-37 or by overnight delivery service, and maintain a log of mailed
8-38 claims and include a copy of the log with the claim;
8-39 (2) submit the claim electronically and maintain a log
8-40 of electronically submitted claims;
8-41 (3) fax the claim and maintain a log of all faxed
8-42 claims; or
8-43 (4) hand deliver the claim and maintain a log of all
8-44 hand-delivered claims.
8-45 (d) If a claim for medical care or health care services
8-46 under a health care plan is mailed, the claim is presumed to have
8-47 been received by the health maintenance organization on the third
8-48 day after the date the claim is mailed or, if the claim is mailed
8-49 using overnight service or return receipt requested, on the date
8-50 the delivery receipt is signed. If the claim is submitted
8-51 electronically, the claim is presumed to have been received on the
8-52 date of the electronic verification of receipt by the health
8-53 maintenance organization or the health maintenance organization's
8-54 clearinghouse. If the health maintenance organization or the
8-55 health maintenance organization's clearinghouse does not provide a
8-56 confirmation within 24 hours of submission by the physician or
8-57 provider, then the physician's or provider's clearinghouse shall
8-58 provide the confirmation. If the claim is faxed, the claim is
8-59 presumed to have been received on the date of the transmission
8-60 acknowledgment. If the claim is hand delivered, the claim is
8-61 presumed to have been received on the date the delivery receipt is
8-62 signed.
8-63 (e) Not later than the 45th day after the date that the
8-64 health maintenance organization receives a clean claim from a
8-65 physician or provider, the health maintenance organization shall
8-66 make a determination of whether the claim is eligible for payment
8-67 and:
8-68 (1) if the health maintenance organization determines
8-69 the entire claim is eligible for payment, pay the total amount of
9-1 the claim in accordance with the contract between the physician or
9-2 provider and the health maintenance organization;
9-3 (2) if the health maintenance organization disputes a
9-4 portion of the claim, pay the portion of the claim that is not in
9-5 dispute and notify the physician or provider in writing why the
9-6 remaining portion of the claim will not be paid; or
9-7 (3) if the health maintenance organization determines
9-8 that the claim is not eligible for payment, notify the physician or
9-9 provider in writing why the claim will not be paid.
9-10 (f) Not later than the 21st day after the date a health
9-11 maintenance organization or the health maintenance organization's
9-12 designated agent affirmatively adjudicates a pharmacy benefit claim
9-13 that is electronically submitted, the health maintenance
9-14 organization shall:
9-15 (1) pay the total amount of the claim; or
9-16 (2) notify the benefit provider of the reasons for
9-17 denying payment of the claim.
9-18 (g) A health maintenance organization that determines under
9-19 Subsection (e) of this section that a claim is eligible for payment
9-20 and does not pay the claim on or before the 45th day after the date
9-21 the health maintenance organization receives a clean claim:
9-22 (1) shall pay the physician or provider making the
9-23 claim the full amount of billed charges submitted on the claim,
9-24 based on the physician's or provider's charges for medical or
9-25 health care services at the time the services are provided and
9-26 interest on the billed charges at a rate of 15 percent annually;
9-27 (2) commits an unfair claim settlement practice in
9-28 violation of Article 21.21, Insurance Code; and
9-29 (3) is subject to an administrative penalty under
9-30 Chapter 84, Insurance Code.
9-31 (h) The investigation and determination of eligibility or
9-32 coverage, including any limitations or exclusions, and coordination
9-33 of other health benefit plan coverage does not extend the period
9-34 for determining whether a claim is eligible for payment under
9-35 Subsection (e) of this section [(d) If a prescription benefit
9-36 claim is electronically adjudicated and electronically paid, and
9-37 the health maintenance organization or its designated agent
9-38 authorizes treatment, the claim must be paid not later than the
9-39 21st day after the treatment is authorized].
9-40 (i) Except as provided by Subsections (j) and (k) of this
9-41 section, if [(e) If] the health maintenance organization
9-42 acknowledges coverage of an enrollee under the health care plan but
9-43 intends to audit the physician or provider claim, the health
9-44 maintenance organization shall pay the charges submitted at 85
9-45 percent of the contracted rate on the claim not later than the 45th
9-46 day after the date that the health maintenance organization
9-47 receives the claim from the physician or provider. The health
9-48 maintenance organization shall complete [Following completion of]
9-49 the audit and make [,] any additional payment due a physician or
9-50 provider or any refund due the health maintenance organization
9-51 [shall be made] not later than the 90th [30th] day after the [later
9-52 of the] date the claim is received by the health maintenance
9-53 organization [that:]
9-54 [(1) the physician or provider receives notice of the
9-55 audit results; or]
9-56 [(2) any appeal rights of the enrollee are exhausted].
9-57 (j) A health maintenance organization may make one request
9-58 for attachments necessary for clarification of a clean claim. The
9-59 request must be in writing and sent to the physician or provider
9-60 that submitted the claim on or before the 30th calendar day after
9-61 the date the health maintenance organization receives the claim.
9-62 The request must describe with specificity the clinical information
9-63 the health maintenance organization can demonstrate is directly
9-64 related to the claim in question or the claim's related episode of
9-65 care. On receipt of all requested attachments, the health
9-66 maintenance organization shall determine whether the claim is
9-67 eligible for payment. Subsections (c) and (d) of this section
9-68 apply to a request for and submission of an attachment under this
9-69 subsection.
10-1 (k) If a health maintenance organization requests an
10-2 attachment from a person other than the physician or provider that
10-3 submits the clean claim, the health maintenance organization must
10-4 provide a copy of the request to the physician or provider who
10-5 submitted the claim. The health maintenance organization may not
10-6 withhold payment pending receipt of information requested from a
10-7 person other than the physician or provider who submitted the
10-8 claim. If on receiving information requested from that person the
10-9 health maintenance organization determines an error in payment of
10-10 the claim, the health maintenance organization may recover under
10-11 Section 18E of this Act.
10-12 (l) The commissioner shall adopt rules under which a health
10-13 maintenance organization can easily identify attachments submitted
10-14 by a physician or health care provider. Rules adopted under this
10-15 subsection may not require the use of additional forms or
10-16 attachments [(f) A health maintenance organization that violates
10-17 Subsection (c) or (e) of this section is liable to a physician or
10-18 provider for the full amount of billed charges submitted on the
10-19 claim or the amount payable under the contracted penalty rate, less
10-20 any amount previously paid or any charge for a service that is not
10-21 covered by the health care plan].
10-22 (m) [(g)] A physician or provider may recover reasonable
10-23 attorney's fees and court costs in an action to recover payment
10-24 under this section.
10-25 (n) [(h) In addition to any other penalty or remedy
10-26 authorized by the Insurance Code or another insurance law of this
10-27 state, a health maintenance organization that violates Subsection
10-28 (c) or (e) of this section is subject to an administrative penalty
10-29 under Article 1.10E, Insurance Code. The administrative penalty
10-30 imposed under that article may not exceed $1,000 for each day the
10-31 claim remains unpaid in violation of Subsection (c) or (e) of this
10-32 section.]
10-33 [(i)] The health maintenance organization shall provide a
10-34 participating physician or provider with copies of all applicable
10-35 utilization review policies and claim processing policies or
10-36 procedures, including required data elements and claim formats.
10-37 (o) [(j) A health maintenance organization may, by contract
10-38 with a physician or provider, add or change the data elements that
10-39 must be submitted with the physician or provider claim.]
10-40 [(k) Not later than the 60th day before the date of an
10-41 addition or change in the data elements that must be submitted with
10-42 a claim or any other change in a health maintenance organization's
10-43 claim processing and payment procedures, the health maintenance
10-44 organization shall provide written notice of the addition or change
10-45 to each participating physician or provider.]
10-46 [(l) This section does not apply to a claim made by a
10-47 physician or provider who is a member of the legislature.]
10-48 [(m)] This section does not apply to a capitation payment
10-49 required to be made to a physician or provider under an agreement
10-50 to provide medical care or health care services under a health care
10-51 plan.
10-52 (p) [(n)] This section applies to a person with whom a
10-53 health maintenance organization contracts to process claims or to
10-54 obtain the services of physicians and providers to provide health
10-55 care services to health care plan enrollees.
10-56 (q) [(o)] The commissioner may adopt rules as necessary to
10-57 implement this section.
10-58 SECTION 6. The Texas Health Maintenance Organization Act
10-59 (Chapter 20A, Vernon's Texas Insurance Code) is amended by adding
10-60 Sections 18D through 18M, 40, and 41 to read as follows:
10-61 Sec. 18D. ELEMENTS OF CLEAN CLAIM. (a) A claim by a
10-62 provider, other than an institutional provider, is a "clean claim"
10-63 if the claim is submitted using Health Care Financing
10-64 Administration Form 1500 or another Health Care Financing
10-65 Administration form adopted by the commissioner by rule for the
10-66 purposes of this subsection that is submitted to a health
10-67 maintenance organization for payment and that contains the
10-68 information required by the commissioner by rule for the purposes
10-69 of this subsection entered into the appropriate fields on the form.
11-1 (b) A claim by an institutional provider is a "clean claim"
11-2 if the claim is submitted using Health Care Financing
11-3 Administration Form UB-92 or another Health Care Financing
11-4 Administration form adopted by the commissioner by rule for the
11-5 purposes of this subsection that is submitted to a health
11-6 maintenance organization for payment and that contains the
11-7 information required by the commissioner by rule for the purposes
11-8 of this subsection entered into the appropriate fields on the form.
11-9 (c) A health maintenance organization may require any data
11-10 element that is required in an electronic transaction set needed to
11-11 comply with federal law. A health maintenance organization may not
11-12 require a provider to provide information other than information
11-13 for a data field included on the form used for a clean claim under
11-14 Subsection (a) or (b) of this section, as applicable.
11-15 (d) A claim submitted by a physician or provider that
11-16 includes additional fields, data elements, attachments, or other
11-17 information not required under this section is considered to be a
11-18 clean claim for the purposes of this section.
11-19 Sec. 18E. OVERPAYMENT. A health maintenance organization
11-20 may recover an overpayment to a physician or provider if:
11-21 (1) not later than the 180th day after the date the
11-22 physician or provider receives the payment, the health maintenance
11-23 organization provides written notice of the overpayment to the
11-24 physician or provider that includes the basis and specific reasons
11-25 for the request for recovery of funds; and
11-26 (2) the physician or provider does not make
11-27 arrangements for repayment of the requested funds on or before the
11-28 45th day after the date the physician or provider receives the
11-29 notice.
11-30 Sec. 18F. VERIFICATION OF COVERAGE. (a) On the request of
11-31 a physician or provider for verification of the payment eligibility
11-32 of a particular medical care or health care service the physician
11-33 or provider proposes to provide to a particular patient, the health
11-34 maintenance organization shall inform the physician or provider
11-35 whether the service, if provided to that patient, is eligible for
11-36 payment from the health maintenance organization to the physician
11-37 or provider.
11-38 (b) A health maintenance organization shall provide
11-39 verification under this section between 6 a.m. and 6 p.m. central
11-40 standard time each day.
11-41 (c) Verification under this section shall be made in good
11-42 faith and without delay.
11-43 Sec. 18G. COORDINATION OF BENEFITS. (a) A health
11-44 maintenance organization may require a physician or provider to
11-45 retain in the physician's or provider's records updated information
11-46 concerning other health benefit plan coverage and to provide the
11-47 information to the health maintenance organization on the
11-48 applicable form described by Section 18D of this Act. Except as
11-49 provided by this subsection, a health maintenance organization may
11-50 not require a physician or provider to investigate coordination of
11-51 other health benefit plan coverage. This provision may not be
11-52 waived, voided, or nullified by contract.
11-53 (b) Coordination of other health benefit plan coverage does
11-54 not extend the period for determining whether a claim is eligible
11-55 for payment under Section 18B(e) of this Act.
11-56 (c) A physician or provider who submits a claim for
11-57 particular medical or health care services to more than one health
11-58 maintenance organization or insurer shall provide written notice
11-59 on the claim submitted to each health maintenance organization or
11-60 insurer of the identity of each other health maintenance
11-61 organization or insurer with which the same claim is being filed.
11-62 (d) On receipt of notice under Subsection (c) of this
11-63 section, a health maintenance organization shall coordinate and
11-64 determine the appropriate payment for each health maintenance
11-65 organization or insurer to make to the physician or provider.
11-66 (e) If a health maintenance organization is a secondary
11-67 payor and pays more than the amount for which the health
11-68 maintenance organization is legally obligated, the overpayment may
11-69 be recovered from the health maintenance organization or insurer
12-1 that is primarily responsible for the amount overpaid by the
12-2 secondary health maintenance organization.
12-3 (f) If the portion of the claim overpaid by the secondary
12-4 health maintenance organization was also paid by the primary health
12-5 maintenance organization or insurer, the secondary health
12-6 maintenance organization may recover the amount of the overpayment
12-7 under Section 18E of this Act from the physician or provider who
12-8 received the payment.
12-9 (g) A health maintenance organization may share information
12-10 with another health maintenance organization or insurer to the
12-11 extent necessary to coordinate payment of benefits on a specific
12-12 claim to the limited extent necessary to coordinate appropriate
12-13 payment obligations.
12-14 Sec. 18H. PREAUTHORIZATION OF MEDICAL AND HEALTH CARE
12-15 SERVICES. (a) A health maintenance organization that uses a
12-16 preauthorization process for medical and health care services shall
12-17 provide each participating physician or provider, not later than
12-18 the 10th working day after the date a request is made, a list of
12-19 the medical and health care services that do not require
12-20 preauthorization and information concerning the preauthorization
12-21 process.
12-22 (b) If proposed medical or health care services require
12-23 preauthorization by a health maintenance organization as a
12-24 condition of the health maintenance organization's payment to a
12-25 physician or provider or a physician or provider requests
12-26 preauthorization of proposed medical or health care services, the
12-27 health maintenance organization shall determine whether the medical
12-28 or health care services proposed to be provided to the enrollee are
12-29 medically necessary and appropriate in a manner consistent with
12-30 Article 21.58A, Insurance Code.
12-31 (c) On receipt of a request from a physician or provider for
12-32 preauthorization of proposed medical or health care services, the
12-33 health maintenance organization shall review and issue a
12-34 determination indicating whether the services are preauthorized.
12-35 If the determination requires a determination of medical necessity
12-36 and appropriateness of the proposed medical or health care
12-37 services, the determination must be made within the time frame for
12-38 a utilization review required by Section 5, Article 21.58A,
12-39 Insurance Code.
12-40 (d) If the proposed medical or health care services involve
12-41 inpatient care, the determination issued by the health maintenance
12-42 organization must specify an approved length of stay for admission
12-43 into a health care facility based on the recommendation of the
12-44 patient's physician or provider and the health maintenance
12-45 organization's written medically acceptable screening criteria and
12-46 review procedures. The criteria and procedures must be
12-47 established, periodically evaluated, and updated as required by
12-48 Section 4(i), Article 21.58A, Insurance Code.
12-49 (e) If the health maintenance organization has preauthorized
12-50 medical or health care services, the health maintenance
12-51 organization may not deny or reduce payment to the physician or
12-52 provider for those services unless the physician or provider has
12-53 materially misrepresented the proposed medical or health care
12-54 services or has substantially failed to perform the proposed
12-55 medical or health care services.
12-56 (f) This section applies to an agent or other person with
12-57 whom a health maintenance organization contracts to perform, or to
12-58 whom the health maintenance organization delegates the performance
12-59 of, preauthorization of proposed medical or health care services.
12-60 Sec. 18I. RETROSPECTIVE REVIEW. (a) A health maintenance
12-61 organization that makes an adverse determination to deny or reduce
12-62 payment to a physician or provider who provided medical or health
12-63 care services with a retrospective review of the medical necessity
12-64 and appropriateness of those services must conduct the
12-65 retrospective review in compliance with the standards for a
12-66 utilization review required by Sections 4(b), (c), (d), (f), (h),
12-67 (i), (l), and (m), Article 21.58A, Insurance Code.
12-68 (b) A health maintenance organization that makes an adverse
12-69 determination to deny or reduce payment to a physician or provider
13-1 based on a retrospective review of the medical necessity and
13-2 appropriateness of the medical or health care services shall notify
13-3 the physician or provider of the determination not later than the
13-4 45th day after the date the health maintenance organization
13-5 receives a clean claim, as defined by Section 18B of this Act, from
13-6 the physician or provider.
13-7 (c) A notice of adverse determination required by Subsection
13-8 (b) of this section must include:
13-9 (1) the principal reasons for the adverse
13-10 determination;
13-11 (2) the clinical basis for the adverse determination;
13-12 (3) a description or the source of the screening
13-13 criteria used as a guideline in making the determination; and
13-14 (4) a description of the procedure for the complaint
13-15 and appeal process, including an appeal of an adverse determination
13-16 to an independent review organization.
13-17 (d) The procedure for appeal must be reasonable and must
13-18 comply with Sections 6(b)(1), (2), (3), (5), and (6), and Section
13-19 6A, Article 21.58A, Insurance Code.
13-20 (e) An adverse determination described by this section is
13-21 eligible for review under Section 6A, Article 21.58A, Insurance
13-22 Code, if the determination relates to:
13-23 (1) a single submitted charge of more than $650; or
13-24 (2) two or more submitted charges for the same or
13-25 similar services with a cumulative amount of more than $650.
13-26 (f) This section applies to an agent or other person with
13-27 whom a health maintenance organization contracts to perform, or to
13-28 whom the health maintenance organization delegates the performance
13-29 of, retrospective review of medical or health care services.
13-30 Sec. 18J. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND
13-31 PROVIDERS. The provisions of this Act relating to prompt payment
13-32 by a health maintenance organization of a physician or provider and
13-33 to preauthorization and retrospective review of medical or health
13-34 care services apply to a physician or health care provider who:
13-35 (1) is not included in the health maintenance
13-36 organization delivery network; and
13-37 (2) provides to an enrollee:
13-38 (A) emergency care; or
13-39 (B) specialty or other medical or health care
13-40 services at the request of the health maintenance organization or a
13-41 physician or provider who is included in the health maintenance
13-42 organization delivery network because the services are not
13-43 reasonably available within the network.
13-44 Sec. 18K. AVAILABILITY OF CODING GUIDELINES. (a) A
13-45 contract between a health maintenance organization and a physician
13-46 or provider must provide that:
13-47 (1) the physician or provider may request a copy of
13-48 the coding guidelines, including any underlying bundling, recoding,
13-49 or other payment process and fee schedules applicable to specific
13-50 procedures that the physician or provider will receive under the
13-51 contract;
13-52 (2) the health maintenance organization will provide
13-53 the guidelines not later than the 30th day after the date the
13-54 health maintenance organization receives the request;
13-55 (3) the health maintenance organization will provide
13-56 notice of material changes to the coding guidelines and fee
13-57 schedules not later than the 90th day before the date the changes
13-58 take effect and will not make retroactive revisions to the coding
13-59 guidelines and fee schedules; and
13-60 (4) the contract may be terminated by the physician or
13-61 provider on or before the 30th day after the date the physician or
13-62 provider receives information requested under this subsection
13-63 without penalty or discrimination in participation in other health
13-64 care products or plans.
13-65 (b) A physician or provider who receives information under
13-66 Subsection (a) of this section may use or disclose the information
13-67 only for the purpose of practice management, billing activities, or
13-68 other business operations. The commissioner may impose and collect
13-69 a penalty of $1,000 for each use or disclosure of the information
14-1 that violates this subsection.
14-2 Sec. 18L. DISPUTE RESOLUTION. (a) An agreement or contract
14-3 provision that requires the use of binding arbitration to resolve
14-4 future disputes in a contract between a health maintenance
14-5 organization and a physician or provider is not enforceable if the
14-6 agreement or provision is unconscionable at the time the agreement
14-7 is made. This subsection does not prohibit a health maintenance
14-8 organization from offering a dispute resolution procedure or
14-9 binding arbitration to resolve a dispute if the health maintenance
14-10 organization and the physician or provider consent to the process
14-11 after the dispute arises. This subsection may not be construed to
14-12 conflict with any applicable appeal mechanisms required by law.
14-13 (b) The provisions of this section may not be waived or
14-14 nullified by contract.
14-15 Sec. 18M. AUTHORITY OF ATTORNEY GENERAL. In addition to any
14-16 other remedy available for a violation of this Act, the attorney
14-17 general may take action and seek remedies available under Section
14-18 15, Article 21.21, Insurance Code, and Sections 17.58, 17.60,
14-19 17.61, and 17.62, Business & Commerce Code, for a violation of
14-20 Section 14 or 18B of this Act.
14-21 Sec. 40. CONFLICT WITH OTHER LAW. To the extent of any
14-22 conflict between this Act and Article 21.52C, Insurance Code, this
14-23 Act controls.
14-24 Sec. 41. APPLICATION OF CERTAIN PROVISIONS UNDER MEDICAID.
14-25 A provision of this Act may not be interpreted as requiring a
14-26 health maintenance organization, physician, or provider, in
14-27 providing benefits or services under the state Medicaid program,
14-28 to:
14-29 (1) use billing forms or codes that are inconsistent
14-30 with those required under the state Medicaid program; or
14-31 (2) make determinations relating to medical necessity
14-32 or appropriateness or eligibility for coverage in a manner
14-33 different than that required under the state Medicaid program.
14-34 SECTION 7. Subsection (d), Section 5, Article 21.58A,
14-35 Insurance Code, is amended to read as follows:
14-36 (d) The notification of adverse determination required by
14-37 this section shall be provided by the utilization review agent:
14-38 (1) within one calendar [working] day by telephone or
14-39 electronic transmission to the provider of record in the case of a
14-40 patient who is hospitalized at the time of the adverse
14-41 determination, to be followed within three working days by written
14-42 notification to [a letter notifying] the enrollee or a person
14-43 acting on behalf of the enrollee [patient] and, if the original
14-44 notification to the provider was not in writing, to the provider of
14-45 record of an adverse determination [within three working days];
14-46 (2) within three working days by written notification
14-47 [in writing] to the provider of record and the patient if the
14-48 patient is not hospitalized at the time of the adverse
14-49 determination; or
14-50 (3) within the time appropriate to the circumstances
14-51 relating to the delivery of the services and the condition of the
14-52 patient, but in no case to exceed one hour from notification when
14-53 denying poststabilization care subsequent to emergency treatment as
14-54 requested by a treating physician or provider. In such
14-55 circumstances, notification of an adverse determination shall be
14-56 provided to the treating physician or health care provider to be
14-57 followed within three working days by written notification to the
14-58 enrollee or a person acting on behalf of the enrollee and, if the
14-59 original notification to the provider was not in writing, the
14-60 provider of record.
14-61 SECTION 8. Subsections (a) and (b), Section 7, Article
14-62 21.58A, Insurance Code, are amended to read as follows:
14-63 (a) A utilization review agent shall have appropriate
14-64 licensed clinical personnel, including physician reviewers,
14-65 reasonably available each day by toll-free telephone from 6 a.m. to
14-66 6 p.m. central standard time [at least 40 hours per week during
14-67 normal business hours in Texas] to discuss patients' care, [and]
14-68 allow response to telephone review requests, and provide the
14-69 notification required by Section 5 of this article.
15-1 (b) A utilization review agent must have a telephone system
15-2 capable of accepting or recording or providing instructions to
15-3 incoming phone calls, supported by on-call licensed personnel,
15-4 between 6 p.m. and 6 a.m. central standard time each day [during
15-5 other than normal business hours] and shall respond to such calls
15-6 not later than one day after [two working days of the later of] the
15-7 date on which the call was received or within one hour of the time
15-8 a request for poststabilization care is received [the date the
15-9 details necessary to respond have been received from the caller].
15-10 SECTION 9. (a) The changes in law made by this Act relating
15-11 to payment of a physician or health care provider for medical or
15-12 health care services apply only to payment for services provided on
15-13 or after the effective date of this Act.
15-14 (b) The changes in law made by this Act relating to a
15-15 contract between a physician or health care provider and an insurer
15-16 or health maintenance organization apply only to a contract entered
15-17 into on or after the effective date of this Act.
15-18 SECTION 10. This Act takes effect September 1, 2001.
15-19 * * * * *