79R2259 AJA-D

By:  Deuell                                                       S.B. No. 1517



A BILL TO BE ENTITLED

AN ACT

relating to qualifications of physicians who perform certain 
utilization review duties for a health benefit plan.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:                        
	SECTION 1.  Section 4(h), Article 21.58A, Insurance Code, is 
amended to read as follows:
	(h)  Utilization review conducted by a utilization review 
agent shall be under the direction of a physician licensed to 
practice medicine in this [by a] state [licensing agency in the 
United States].
	SECTION 2.  Article 21.58A, Insurance Code, is amended by 
adding Section 4A to read as follows:
	Sec. 4A.  TEXAS LICENSE REQUIRED FOR CERTAIN PHYSICIANS.  A 
physician who performs any of the following duties with respect to 
health care provided in this state for a utilization review agent 
must be licensed as a doctor of medicine or osteopathy in this 
state:
		(1)  reviewing, developing standards for, or approving 
a utilization review plan under Section 4(b) or 14(j)(1) of this 
article;
		(2)  discussing a plan of treatment for a patient and 
the clinical basis for the utilization review agent's decision with 
a patient's health care provider under Section 4(k) or Section 
14(j)(4) of this article;
		(3)  making an appeal decision under Section 6(b)(3) or 
Section 14(j)(5) of this article;
		(4)  being involved in establishing written screening 
criteria for utilization review or for a retrospective review of 
the medical necessity and appropriateness of a health care service 
under Section 4(i) or 11(a)(1) of this article;
		(5)  directing a payor's system for retrospective 
review under Section 11(a)(2) of this article; or
		(6)  directing the conduct of utilization review under 
Section 4(h) or 14(j)(3) of this article.
	SECTION 3.  Section 14(j), Article 21.58A, Insurance Code, 
is amended to read as follows:
	(j)  A specialty utilization review agent is not subject to 
Section 4(b), (c), (h), or (k) or Section 6(b)(3) of this article.  
For purposes of this subsection, a specialty utilization review 
agent means a utilization review agent that conducts utilization 
review for specialty health care services, including but not 
limited to dentistry, chiropractic, or physical therapy.  A 
specialty utilization review agent shall comply with the following 
requirements:
		(1)  the utilization review plan, including 
reconsideration and appeal requirements, shall be reviewed by a 
health care provider of the appropriate specialty and conducted in 
accordance with standards developed with input from a health care 
provider of the appropriate specialty;
		(2)  personnel employed by or under contract with a 
specialty utilization review agent to perform utilization review 
shall be appropriately trained and qualified.  Personnel who obtain 
information directly from the physician or health care provider, 
either orally or in writing, shall be nurses, physician assistants, 
or other health care providers of the same specialty as the 
utilization review agent and who are licensed or otherwise 
authorized to provide the specialty health care service by a state 
licensing agency in the United States, except that this provision 
does not require those qualifications for personnel who perform 
solely clerical or administrative tasks;
		(3)  utilization review conducted by a specialty 
utilization review agent shall be conducted under the direction of 
a health care provider of the same specialty and, except as provided 
by Section 4A of this article, shall be licensed or otherwise 
authorized to provide the specialty health care service by a state 
licensing agency in the United States;
		(4)  subject to the notice requirements of Section 5 of 
this article, in any instance where the specialty utilization 
review agent questions the medical necessity or appropriateness of 
health care services, the health care provider who ordered the 
services shall, prior to the issuance of an adverse determination, 
be afforded a reasonable opportunity to discuss the plan of 
treatment for the patient and the clinical basis for the decision of 
the utilization review agent with a health care provider of the same 
specialty as the utilization review agent;  and
		(5)  appeal decisions shall be made by a physician or 
health care provider in the same or a similar specialty as typically 
manages the medical, dental, or specialty condition, procedure, or 
treatment under discussion for review of the adverse determination.
	SECTION 4.  The change in law made by this Act applies only 
to an action of a physician on or after January 1, 2006.  An action 
of a physician before January 1, 2006, is governed by the law in 
effect immediately before the effective date of this Act, and that 
law is continued in effect for that purpose.
	SECTION 5.  This Act takes effect September 1, 2005.