Floor Packet Page No. 387
Amend CSHB 4 by adding the following appropriately numbered
ARTICLES and renumbering existing ARTICLES and SECTIONS of the bill
appropriately:
ARTICLE ___. PROMPT PAYMENT OF PHYSICIANS AND HEALTH CARE
PROVIDERS
SECTION ___.01. Sections 3A(c) and (e), Article 3.70-3C,
Insurance Code, as added by Chapter 1024, Acts of the 75th
Legislature, Regular Session, 1997, are amended to read as follows:
(c) Not later than the 30th [45th] day after the date that
the insurer receives a clean claim from a preferred provider, the
insurer shall:
(1) pay the total amount of the claim in accordance
with the contract between the preferred provider and the insurer;
(2) pay the portion of the claim that is not in dispute
and notify the preferred provider in writing why the remaining
portion of the claim will not be paid; or
(3) notify the preferred provider in writing why the
claim will not be paid.
(e) If the insurer acknowledges coverage of an insured under
the health insurance policy but intends to audit the preferred
provider claim, the insurer shall pay the charges submitted at 85
percent of the contracted rate on the claim not later than the 30th
[45th] day after the date that the insurer receives the claim from
the preferred provider. Following completion of the audit, any
additional payment due a preferred provider or any refund due the
insurer shall be made not later than the 30th day after the later of
the date that:
(1) the preferred provider receives notice of the
audit results; or
(2) any appeal rights of the insured are exhausted.
SECTION ___.02. Sections 843.338, 843.340, and 843.346,
Insurance Code, as effective June 1, 2003, are amended to read as
follows:
Sec. 843.338. DEADLINE FOR ACTION ON CLEAN CLAIMS. Not
later than the 30th [45th] day after the date on which a health
maintenance organization receives a clean claim from a physician or
provider, the health maintenance organization shall:
(1) pay the total amount of the claim in accordance
with the contract between the physician or provider and the health
maintenance organization;
(2) pay the portion of the claim that is not in dispute
and notify the physician or provider in writing why the remaining
portion of the claim will not be paid; or
(3) notify the physician or provider in writing why
the claim will not be paid.
Sec. 843.340. AUDITED CLAIMS. A health maintenance
organization that acknowledges coverage of an enrollee under a
health care plan but intends to audit a claim submitted by a
physician or provider shall pay the charges submitted at 85 percent
of the contracted rate on the claim not later than the 30th [45th]
day after the date on which the health maintenance organization
receives the claim from a physician or provider. Following
completion of the audit, any additional payment due a physician or
provider or any refund due the health maintenance organization
shall be made not later than the 30th day after the later of the date
that:
(1) the physician or provider receives notice of the
audit results; or
(2) any appeal rights of the enrollee are exhausted.
Sec. 843.346. PAYMENT OF CLAIMS. Subject to Sections
843.336-843.345, a health maintenance organization shall pay a
physician or provider for health care services and benefits
provided to an enrollee under the evidence of coverage and to which
the enrollee is entitled under the terms of the evidence of coverage
not later than:
(1) the 30th [45th] day after the date on which a claim
for payment is received with the documentation reasonably necessary
to process the claim; or
(2) if applicable, within the number of calendar days
specified by written agreement between the physician or provider
and the health maintenance organization.
SECTION ___.03. This article applies only to a claim for
payment made under a benefit plan or evidence of coverage
delivered, issued for delivery, or renewed on or after September 1,
2003. A benefit plan or evidence of coverage delivered, issued for
delivery, or renewed before September 1, 2003, is governed by the
law in effect immediately before that date and that law is continued
in effect for this purpose.
ARTICLE ___. PROFESSIONAL LIABILITY INSURANCE FOR PHYSICIANS AND
HEALTH CARE PROVIDERS
SECTION ___.01. Article 5.15-1, Insurance Code, is amended
by adding Section 12 to read as follows:
Sec. 12. RATE ROLLBACK. (a) Except as provided by
Subsection (b) of this section, this section applies only to an
insurer writing professional liability insurance for physicians
and health care providers in this state on August 31, 2003, or a
person classified as an affiliate of one of those insurers under
Section 823.003 of this code.
(b) A person that is classified as an affiliate of an
insurer under Section 823.003 of this code and that begins writing
professional liability insurance for physicians and health care
providers on or after September 1, 2003, may not charge an amount
for professional liability insurance for physicians and health care
providers issued or renewed in this state that exceeds the amount
that the company described by Subsection (a) of this section with
which the person is affiliated may charge for the insurance under
this section.
(c) An insurer may not charge an insured for professional
liability insurance for physicians and health care providers issued
or renewed on or after September 1, 2003, an amount that exceeds 85
percent of the amount the insurer charged that insured for the same
coverage immediately before September 1, 2003, or, if the insurer
did not insure that insured immediately before that date, the
amount that the insurer would have charged the insured at that time.