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Amend CSHB 1613 (House Committee Printing) by adding the
following appropriately numbered SECTION to the bill and
renumbering subsequent SECTIONS accordingly:
SECTION ____. (a) Section 843.338, Insurance Code, is
amended to read as follows:
Sec. 843.338. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except
as provided by Sections [Section] 843.3385 and 843.339, not later
than the 45th day after the date on which a health maintenance
organization receives a clean claim from a participating physician
or provider in a nonelectronic format or the 30th day after the date
the health maintenance organization receives a clean claim from a
participating physician or provider that is electronically
submitted, the health maintenance organization shall make a
determination of whether the claim is payable and:
(1) if the health maintenance organization determines
the entire claim is payable, pay the total amount of the claim in
accordance with the contract between the physician or provider and
the health maintenance organization;
(2) if the health maintenance organization determines
a portion of the claim is payable, 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) if the health maintenance organization determines
that the claim is not payable, notify the physician or provider in
writing why the claim will not be paid.
(b) Section 843.339, Insurance Code, is amended to read as
follows:
Sec. 843.339. DEADLINE FOR ACTION ON [CERTAIN] PRESCRIPTION
CLAIMS; PAYMENT. (a) Not later than the 21st day after the date a
health maintenance organization affirmatively adjudicates a
pharmacy claim that is electronically submitted, the health
maintenance organization shall pay the total amount of the claim. A
health maintenance organization shall pay a pharmacy claim that is
submitted in a nonelectronic format not later than the deadline
provided under Section 843.338.
(b) Except as provided by Subsection (c), a pharmacy benefit
manager that administers a pharmacy claim for a health maintenance
organization shall pay the provider through electronic funds
transfer not later than the 14th day after the date on which the
claim is determined under this subchapter to be affirmatively
adjudicated.
(c) If the provider is unable to receive payment of a claim
described by Subsection (b) through electronic funds transfer, the
pharmacy benefit manager shall pay the claim not later than the 21st
day after the date on which the claim is determined under this
subchapter to be affirmatively adjudicated.
(c) Section 843.340, Insurance Code, is amended by adding
Subsection (f) to read as follows:
(f) A pharmacy benefit manager who performs an on-site audit
under this chapter of a provider who is a pharmacist or pharmacy
shall provide the provider written notice of the audit and it must
be sent by certified mail not later than the 15th day before the
date on which the audit is scheduled to occur.
(d) Section 1301.001(1), Insurance Code, is amended to read
as follows:
(1) "Health care provider" means a practitioner,
institutional provider, or other person or organization that
furnishes health care services and that is licensed or otherwise
authorized to practice in this state. The term includes a
pharmacist and a pharmacy. The term does not include a physician.
(e) Section 1301.103, Insurance Code, is amended to read as
follows:
Sec. 1301.103. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except
as provided by Sections 1301.104 and [Section] 1301.1054, not later
than the 45th day after the date an insurer receives a clean claim
from a preferred provider in a nonelectronic format or the 30th day
after the date an insurer receives a clean claim from a preferred
provider that is electronically submitted, the insurer shall make a
determination of whether the claim is payable and:
(1) if the insurer determines the entire claim is
payable, pay the total amount of the claim in accordance with the
contract between the preferred provider and the insurer;
(2) if the insurer determines a portion of the claim is
payable, 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) if the insurer determines that the claim is not
payable, notify the preferred provider in writing why the claim
will not be paid.
(f) Section 1301.104, Insurance Code, is amended to read as
follows:
Sec. 1301.104. DEADLINE FOR ACTION ON [CERTAIN] PHARMACY
CLAIMS; PAYMENT. (a) Not later than the 21st day after the date an
insurer affirmatively adjudicates a pharmacy claim that is
electronically submitted, the insurer shall pay the total amount of
the claim. An insurer shall pay a pharmacy claim that is submitted
in a nonelectronic format not later than the deadline provided
under Section 1301.103.
(b) Except as provided by Subsection (c), a pharmacy benefit
manager that administers a pharmacy claim for an insurer under a
preferred provider benefit plan shall pay the provider through
electronic funds transfer not later than the 14th day after the date
on which the claim is determined under this subchapter to be
affirmatively adjudicated.
(c) If the provider is unable to receive payment of a claim
described by Subsection (b) through electronic funds transfer, the
pharmacy benefit manager shall pay the claim not later than the 21st
day after the date on which the claim is determined under this
subchapter to be affirmatively adjudicated.
(g) Section 1301.105, Insurance Code, is amended by adding
Subsection (e) to read as follows:
(e) A pharmacy benefit manager who performs an on-site audit
under this chapter of a provider who is a pharmacist or pharmacy
shall provide the provider reasonable written notice of the audit
and it must be sent by certified mail not later than the 15th day
before the date on which the audit is scheduled to occur.
(h) The change in law made by this section applies only to a
claim submitted by a provider to a health maintenance organization
or an insurer on or after the effective date of this Act. A claim
submitted before the effective date of this Act is governed by the
law as it existed immediately before that date, and that law is
continued in effect for that purpose.