78R8325 DLF-D
By: Davis of Dallas H.B. No. 2235
A BILL TO BE ENTITLED
AN ACT
relating to operations of physicians and other health care
providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. PROMPT PAYMENT OF PHYSICIANS AND HEALTH CARE PROVIDERS
SECTION 1.01. 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 1.02. 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 1.03. 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 the
effective date of this Act. A benefit plan or evidence of coverage
delivered, issued for delivery, or renewed before the effective
date of this Act is governed by the law in effect immediately before
that date and that law is continued in effect for this purpose.
ARTICLE 2. PROFESSIONAL LIABILITY INSURANCE
SECTION 2.01. (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 the effective date of this Act or a
person classified as an affiliate of one of those insurers under
Section 823.003, Insurance Code.
(b) A person that is classified as an affiliate of an
insurer under Section 823.003, Insurance Code, and that begins
writing professional liability insurance for physicians and health
care providers on or after the effective date of this Act, 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 an amount for
professional liability insurance for physicians and health care
providers issued or renewed on or after the effective date of this
Act that exceeds 85 percent of the amount the insurer charged that
insured for the same coverage immediately before that date 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.
ARTICLE 3. MEDICAID REIMBURSEMENT RATES
SECTION 3.01. In this article, "commission" means the
Health And Human Services Commission.
SECTION 3.02. In adopting reasonable rules and standards
governing the determination of fees, charges, and rates for medical
assistance payments under Chapter 32, Human Resources Code, in
accordance with Section 531.021, Government Code, and other law,
the commission shall ensure that the fee, charge, or rate for
services provided by a physician or other health care provider
through the medical assistance program is at least 110 percent of
the applicable rate on January 1, 2003.
SECTION 3.03. This article applies only to fees, charges,
and rates for medical assistance payments under Chapter 32, Human
Resources Code, for services provided on or after the effective
date of this Act.
ARTICLE 4. EFFECTIVE DATE
SECTION 4.01. This Act takes effect September 1, 2003.