By: Van de Putte S.R. No. 1254
SENATE RESOLUTION
1-1 BE IT RESOLVED by the Senate of the State of Texas, 77th
1-2 Legislature, Regular Session, 2001, That Senate Rule 12.03 be
1-3 suspended in part as provided by Senate Rule 12.08 to enable the
1-4 conference committee appointed to resolve the differences on House
1-5 Bill No. 1862, relating to the regulation and prompt payment of
1-6 health care providers under certain health benefit plans and
1-7 providing penalties, to consider and take action on the following
1-8 matters:
1-9 1. Senate Rule 12.03(1) is suspended to permit the committee
1-10 to change text that is not in disagreement in amended Section
1-11 3A(b), Article 3.70-3C, Insurance Code, as added by Chapter 1024,
1-12 Acts of the 75th Legislature, Regular Session, 1997, so that the
1-13 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
1-25 subsection is a result of a catastrophic event that substantially
2-1 interferes with the normal business operations of the physician or
2-2 provider. The period for submitting a claim under this subsection
2-3 may be extended by contract. A physician or provider may not
2-4 submit a duplicate claim for payment before the 46th day after the
2-5 date the original claim was submitted. The commissioner shall
2-6 adopt rules under which an insurer may determine whether a claim is
2-7 a duplicate claim [for medical care or health care services under a
2-8 health insurance policy may obtain acknowledgment of receipt of a
2-9 claim for medical care or health care services under a health care
2-10 plan by submitting the claim by United States mail, return receipt
2-11 requested. An insurer or the contracted clearinghouse of an
2-12 insurer that receives a claim electronically shall acknowledge
2-13 receipt of the claim by an electronic transmission to the preferred
2-14 provider and is not required to acknowledge receipt of the claim by
2-15 the insurer in writing].
2-16 Explanation: This change is necessary to prevent a physician
2-17 or provider from forfeiting payment of a claim if a catastrophic
2-18 event prevents the physician or provider from submitting the claim
2-19 in the required time.
2-20 2. Senate Rule 12.03(1) is suspended to permit the committee
2-21 to change text that is not in disagreement in added Section 3A(d),
2-22 Article 3.70-3C, Insurance Code, so that the subsection reads as
2-23 follows:
2-24 (d) If a claim for medical care or health care services
2-25 provided to a patient is mailed, the claim is presumed to have been
2-26 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. Senate Rules 12.03(1) and (2) are suspended to permit the
3-26 committee to change and omit text that is not in disagreement in
4-1 added Section 3A(g), Article 3.70-3C, Insurance Code, so that the
4-2 subsection reads as follows:
4-3 (g) An insurer that determines under Subsection (e) of this
4-4 section that a claim is eligible for payment and does not pay the
4-5 claim on or before the 45th day after the date the insurer receives
4-6 a clean claim shall pay the physician or provider making the claim
4-7 the lesser of the full amount of billed charges submitted on the
4-8 claim and interest on the billed charges at a rate of 15 percent
4-9 annually or two times the contracted rate and interest on that
4-10 amount at a rate of 15 percent annually. If the provider submits
4-11 the claim using a form described by Section 3B(a) of this article,
4-12 billed charges shall be established under a fee schedule provided
4-13 by the preferred provider to the insurer on or before the 30th day
4-14 after the date the physician or provider enters into a preferred
4-15 provider contract with the insurer. The preferred provider may
4-16 modify the fee schedule if the provider notifies the insurer of the
4-17 modification on or before the 90th day before the date the
4-18 modification takes effect.
4-19 Explanation: This change is necessary to omit language
4-20 relating to payment of certain claims and change the consequences
4-21 of failing to pay certain claims as required.
4-22 4. Senate Rule 12.03(1) is suspended to permit the committee
4-23 to change text that is not in disagreement in added Section 3B(a),
4-24 Article 3.70-3C, Insurance Code, to add the phrase "in the manner
4-25 prescribed".
4-26 Explanation: This change is necessary to specify that for a
5-1 claim by certain physicians or providers to be a "clean claim"
5-2 information must be entered into the required form "in the manner
5-3 prescribed".
5-4 5. Senate Rule 12.03(1) is suspended to allow the committee
5-5 to change text that is not in disagreement in amended Section
5-6 18B(b), Texas Health Maintenance Organization Act (Article 20A.18B,
5-7 Vernon's Texas Insurance Code), so that the subsection reads as
5-8 follows:
5-9 (b) A physician or provider must submit a claim under this
5-10 section to a health maintenance organization not later than the
5-11 95th day after the date the physician or provider provides the
5-12 medical care or health care services for which the claim is made.
5-13 A health maintenance organization shall accept as proof of timely
5-14 filing a claim filed in compliance with Subsection (c) of this
5-15 section or information from another health maintenance organization
5-16 showing that the physician or provider submitted the claim to the
5-17 health maintenance organization in compliance with Subsection (c)
5-18 of this section. If a physician or provider fails to submit a
5-19 claim in compliance with this subsection, the physician or provider
5-20 forfeits the right to payment unless the failure to submit the
5-21 claim in compliance with this subsection is a result of a
5-22 catastrophic event that substantially interferes with the normal
5-23 business operations of the physician or provider. The period for
5-24 submitting a claim under this subsection may be extended by
5-25 contract. A physician or provider may not submit a duplicate claim
5-26 for payment before the 46th day after the date the original claim
6-1 was submitted. The commissioner shall adopt rules under which a
6-2 health maintenance organization may determine whether a claim is a
6-3 duplicate claim. [A physician or provider for medical care or
6-4 health care services under a health care plan may obtain
6-5 acknowledgment of receipt of a claim for medical care or health
6-6 care services under a health care plan by submitting the claim by
6-7 United States mail, return receipt requested. A health maintenance
6-8 organization or the contracted clearinghouse of the health
6-9 maintenance organization that receives a claim electronically shall
6-10 acknowledge receipt of the claim by an electronic transmission to
6-11 the physician or provider and is not required to acknowledge
6-12 receipt of the claim by the health maintenance organization in
6-13 writing.]
6-14 Explanation: This change is necessary to prevent a physician
6-15 or provider from forfeiting payment of a claim if a catastrophic
6-16 event prevents the physician or provider from submitting the claim
6-17 in the required time.
6-18 6. Senate Rule 12.03(1) is suspended to allow the committee
6-19 to change text that is not in disagreement in added Section 18B(d),
6-20 Texas Health Maintenance Organization Act (Article 20A.18B,
6-21 Vernon's Texas Insurance Code), so that the subsection reads as
6-22 follows:
6-23 (d) If a claim for medical care or health care services
6-24 provided to a patient is mailed, the claim is presumed to have been
6-25 received by the health maintenance organization on the third day
6-26 after the date the claim is mailed or, if the claim is mailed using
7-1 overnight service or return receipt requested, on the date the
7-2 delivery receipt is signed. If the claim is submitted
7-3 electronically, the claim is presumed to have been received on the
7-4 date of the electronic verification of receipt by the health
7-5 maintenance organization or the health maintenance organization's
7-6 clearinghouse. If the health maintenance organization or the
7-7 health maintenance organization's clearinghouse does not provide a
7-8 confirmation within 24 hours of submission by the physician or
7-9 provider, the physician's or provider's clearinghouse shall provide
7-10 the confirmation. The physician's or provider's clearinghouse must
7-11 be able to verify that the filing contained the correct payor
7-12 identification of the entity to receive the filing. If the claim
7-13 is faxed, the claim is presumed to have been received on the date
7-14 of the transmission acknowledgment. If the claim is hand
7-15 delivered, the claim is presumed to have been received on the date
7-16 the delivery receipt is signed. The commissioner shall promulgate
7-17 a form to be submitted by the physician or provider which easily
7-18 identifies all claims included in each filing which can be utilized
7-19 by the physician or provider as their log.
7-20 Explanation: This change is necessary to require that a
7-21 physician's or provider's clearinghouse be able to verify that a
7-22 filed claim contains the correct "payor identification" of the
7-23 entity to receive the filing, rather than the "correct address" of
7-24 the entity.
7-25 7. Senate Rules 12.03(1) and (2) are suspended to allow the
7-26 committee to change and omit text that is not in disagreement in
8-1 added Section 18B(g), Texas Health Maintenance Organization Act
8-2 (Article 20A.18B, Vernon's Texas Insurance Code), so that the
8-3 subsection reads as follows:
8-4 (g) A health maintenance organization that determines under
8-5 Subsection (e) of this section that a claim is eligible for payment
8-6 and does not pay the claim on or before the 45th day after the date
8-7 the health maintenance organization receives a clean claim shall
8-8 pay the physician or provider making the claim the lesser of the
8-9 full amount of billed charges submitted on the claim and interest
8-10 on the billed charges at a rate of 15 percent annually or two times
8-11 the contracted rate and interest on that amount at a rate of 15
8-12 percent annually. If the physician or provider submits the claim
8-13 using a form described by Section 18D(a) of this Act, billed
8-14 charges shall be established under a fee schedule provided by the
8-15 physician or provider to the health maintenance organization on or
8-16 before the 30th day after the date the physician or provider enters
8-17 into the contract with the health maintenance organization. The
8-18 physician or provider may modify the fee schedule if the physician
8-19 or provider notifies the health maintenance organization of the
8-20 modification on or before the 90th day before the date the
8-21 modification takes effect.
8-22 Explanation: This change is necessary to omit language
8-23 relating to payment of certain claims and change the consequences
8-24 of failing to pay certain claims as required.
8-25 8. Senate Rule 12.03(1) is suspended to allow the committee
8-26 to change text that is not in disagreement in added Section 18D(a),
9-1 Texas Health Maintenance Organization Act, to add the phrase "in
9-2 the manner prescribed".
9-3 Explanation: This change is necessary to specify that for a
9-4 claim by certain physicians or providers to be a "clean claim"
9-5 information must be entered into the required form "in the manner
9-6 prescribed".
9-7 9. Senate Rule 12.03(1) is suspended to allow the committee
9-8 to change text that is not in disagreement in added Section 18H(c),
9-9 Texas Health Maintenance Organization Act, to substitute the phrase
9-10 "health maintenance organization" for "insurer".
9-11 Explanation: This change is necessary to make a technical
9-12 correction that changes "insurer" to "health maintenance
9-13 organization".
9-14 10. Senate Rule 12.03(1) is suspended to allow the committee
9-15 to change text that is not in disagreement in added Section 18I,
9-16 Texas Health Maintenance Organization Act, to change the term
9-17 "preauthorization" to "verification".
9-18 Explanation: This change is necessary to apply the
9-19 provisions of the Texas Health Maintenance Organization Act
9-20 relating to "verification" of certain services, rather than
9-21 provisions relating to "preauthorization" of those services, to
9-22 certain physicians or providers.
9-23 11. Senate Rule 12.03(4) is suspended to allow the committee
9-24 to add a new section to the bill to read as follows:
9-25 SECTION 8. (a) Section 3, Article 21.53Q, Insurance Code,
9-26 as added by House Bill 1676, Acts of the 77th Legislature, Regular
10-1 Session, 2001, is amended to read as follows:
10-2 Sec. 3. TRAINING FOR CERTAIN PERSONNEL REQUIRED. (a) In
10-3 this section, "preauthorization" means a determination by [the
10-4 provision of a reliable representation to a physician or health
10-5 care provider of whether] the issuer of a health benefit plan that
10-6 the [will pay the physician or provider for proposed] medical or
10-7 health care services proposed to be provided [if the physician or
10-8 provider renders those services] to a [the] patient are medically
10-9 necessary and appropriate [for whom the services are proposed].
10-10 The term includes precertification, certification, recertification,
10-11 or any other activity that involves providing a reliable
10-12 representation by the issuer of a health benefit plan to a
10-13 physician or health care provider.
10-14 (b) The commissioner by rule shall require the issuer of a
10-15 health benefit plan to provide adequate training to appropriate
10-16 personnel responsible for preauthorization of coverage, if required
10-17 under the plan, or utilization review under the plan to prevent
10-18 wrongful denial of coverage required under this article and to
10-19 avoid confusion of medical benefits with mental health benefits.
10-20 (b) This section takes effect only if House Bill 1676, Acts
10-21 of the 77th Legislature, Regular Session, 2001, becomes law. If
10-22 House Bill 1676 does not become law, this section has no effect.
10-23 Explanation: This change is necessary to conform the
10-24 definition of "preauthorization" in Section 3, Article 21.53Q,
10-25 Insurance Code, to the definitions of "preauthorization" in House
10-26 Bill No. 1862 and clarify the preauthorization personnel to which
11-1 the training requirement in that section applies.
11-2 ______________________________________
11-3 President of the Senate
11-4 I hereby certify that the above
11-5 Resolution was adopted by the Senate
11-6 on May 27, 2001, by the following
11-7 vote: Yeas 30, Nays 0, one present
11-8 not voting.
11-9 ______________________________________
11-10 Secretary of the Senate