78R3954 DLF-D

By:  Naishtat                                                     H.B. No. 1491



A BILL TO BE ENTITLED

AN ACT

relating to utilization review and independent review of certain 
health care services.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:                        
	SECTION 1.  Section 2(20), Article 21.58A, Insurance Code, 
is amended to read as follows:
		(20)  "Utilization review" means a system for 
prospective, [or] concurrent, or retrospective review of the 
medical necessity and appropriateness of health care services being 
provided, [or] proposed to be provided, or provided to an 
individual within this state. Utilization review shall not include 
elective requests for clarification of coverage.
	SECTION 2.  Section 11, Article 21.58A, Insurance Code, is 
amended to read as follows:
	Sec. 11.  RETROSPECTIVE UTILIZATION REVIEW [CLAIMS REVIEWS] 
OF MEDICAL NECESSITY. [(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.
	[(b)] When an adverse determination is made under a health 
insurance policy or plan based on a retrospective utilization
review of the medical necessity and appropriateness of the 
allocation of health care resources and services, the payor shall 
afford the health care providers the opportunity to appeal the 
determination in the same manner afforded the enrollee, with the 
enrollee's consent to act on his or her behalf, but in no event 
shall health care providers be precluded from appeal if the 
enrollee is not reasonably available or competent to consent.  Such 
appeal shall not be construed to imply or confer on such health care 
providers any contract rights with respect to the enrollee's health 
insurance policy or plan that the health care provider does not 
otherwise have.
	SECTION 3.  Section 14(c), Article 21.58A, Insurance Code, 
is amended to read as follows:
	(c)  Except as otherwise provided by this subsection, this 
article applies to utilization review of health care services 
provided to persons eligible for workers' compensation medical 
benefits under Title 5, Labor Code.  The commissioner shall 
regulate in the manner provided by this article a person who 
performs review of a medical benefit provided under Chapter 408, 
Labor Code.  To the extent this article applies to retrospective 
utilization review, it does not apply to medical dispute resolution 
under Section 413.031, Labor Code. This subsection does not affect 
the authority of the Texas Workers' Compensation Commission to 
exercise the powers granted to that commission under Title 5, Labor 
Code.  In the event of a conflict between this article and Title 5, 
Labor Code, Title 5, Labor Code, prevails.  The commissioner and the 
Texas Workers' Compensation Commission may adopt rules and enter 
into memoranda of understanding as necessary to implement this 
subsection.
	SECTION 4.  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 5.  This Act takes effect September 1, 2003, and 
applies only to a utilization review or independent review under 
Article 21.58A or Article 21.58C, Insurance Code, as applicable, 
that begins on or after January 1, 2004.  A utilization 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.