Amend CSSB 14 by adding the following new ARTICLE, 
appropriately numbered, and renumbering ARTICLES and SECTIONS of 
the bill accordingly:
	ARTICLE _____. INDEPENDENT REVIEW ORGANIZATIONS
	SECTION _____. Section 11, Article 21.58A, Insurance Code, is 
amended by amending Subsection (a) and adding Subsection (c) to 
read as follows:
	(a) When a retrospective review of the medical necessity and 
appropriateness of health care service is made under a health 
insurance policy or plan:
		(1) such retrospective review shall be based on written 
screening criteria established and periodically updated with 
appropriate involvement from physicians, including practicing 
physicians, and other health care providers; [and]
		(2) the payor's system for such retrospective review of 
medical necessity and appropriateness shall be under the direction 
of a physician;
		(3) the retrospective review must comply with the 
confidentiality provisions of Section 8 of this article in the same 
manner as if the person conducting the retrospective review was a 
utilization review agent; and
		(4) the payor shall notify the enrollee or a person 
acting on behalf of the enrollee and the enrollee's provider of 
record of any adverse determination and shall notify the appealing 
party of the right to seek review of the adverse determination by an 
independent review organization under this section.
	(c) A person conducting a retrospective review of the medical 
necessity and appropriateness of health care service under this 
section shall:
		(1) permit any party whose appeal of an adverse 
determination is denied by the person to seek review of that 
determination by an independent review organization assigned to the 
appeal in accordance with Article 21.58C of this code;
		(2) provide to the appropriate independent review 
organization not later than the third business day after the date 
that the person conducting the review receives a request for review 
a copy of:
			(A) any medical records of the enrollee that are 
relevant to the review;
			(B) any documents used by the plan in making the 
determination to be reviewed by the organization;
			(C) a copy of a response letter issued to the 
enrollee or a person acting on behalf of the enrollee, and the 
enrollee's physician or health care provider, explaining the 
resolution of the appeal;
			(D) any documentation and written information 
submitted to the person conducting the review in support of the 
appeal; and
			(E) a list of each physician or health care 
provider who has provided care to the enrollee and who may have 
medical records relevant to the appeal;
		(3) comply with the independent review organization's 
determination with respect to the medical necessity or 
appropriateness of health care items and services for an enrollee; 
and
		(4) pay for the independent review.                                    
	SECTION _____. Section 2(c), Article 21.58C, Insurance Code, 
is amended to read as follows:
	(c) The standards adopted under Subsection (a)(1) of this 
section must include standards that require each independent review 
organization to make its determination:
		(1) not later than the earlier of:                                            
			(A) the 15th day after the date the independent 
review organization receives the information necessary to make the 
determination; or
			(B) the 20th day after the date the independent 
review organization receives the request that the determination be 
made; [and]
		(2) in the case of a life-threatening condition, not 
later than the earlier of:
			(A) the fifth day after the date the independent 
review organization receives the information necessary to make the 
determination; or
			(B) the eighth day after the date the independent 
review organization receives the request that the determination be 
made; and
		(3) in the case of a retrospective review of health care 
services that have been provided, not later than the earlier of:
			(A) the 25th day after the date the independent 
review organization receives the information necessary to make the 
determination; or
			(B) the 30th day after the date the independent 
review organization receives the request that the determination be 
made.
	SECTION _____. The change in law made by this article to 
Articles 21.58A and 21.58C, Insurance Code, applies only to a 
retrospective review or independent review under those articles, as 
applicable, that begins on or after January 1, 2004.  A 
retrospective review or independent review that begins before 
January 1, 2004, is governed by the law as it existed immediately 
before the effective date of this Act and that law is continued in 
effect for this purpose.