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A BILL TO BE ENTITLED
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AN ACT
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relating to professional licensing requirements for independent |
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review of certain medical decisions regarding workers' |
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compensation claims. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 401.011, Labor Code, is amended by |
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adding Subdivision (25-a) to read as follows: |
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(25-a) "Independent review organization" has the same |
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meaning as in Section 1305.004(a)(11), Insurance Code. |
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SECTION 2. Section 413.031, Labor Code, is amended by |
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amending Subsections (d) and (e) and adding Subsection (e-2) to |
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read as follows: |
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(d) A review of the medical necessity of a health care |
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service requiring preauthorization under Section 413.014 or |
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commissioner rules under that section or Section 413.011(g) shall |
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be conducted by an independent review organization under Chapter |
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4202 [Article 21.58C], Insurance Code, in the same manner as |
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reviews of utilization review decisions by health maintenance |
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organizations. It is a defense for the insurance carrier if the |
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carrier timely complies with the decision of the independent review |
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organization. |
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(e) Except as provided by Subsections (d), (f), and (m), a |
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review of the medical necessity of a health care service provided |
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under this chapter or Chapter 408 shall be conducted by an |
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independent review organization under Chapter 4202 [Article
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21.58C], Insurance Code, in the same manner as reviews of |
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utilization review decisions by health maintenance organizations. |
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It is a defense for the insurance carrier if the carrier timely |
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complies with the decision of the independent review organization. |
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(e-2) Notwithstanding Section 4202.002, Insurance Code, an |
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independent review organization that uses doctors to perform |
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reviews of health care services provided under this title may only |
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use doctors licensed to practice in this state. |
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SECTION 3. Sections 1305.355(a) and (d), Insurance Code, |
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are amended to read as follows: |
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(a) The utilization review agent shall: |
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(1) permit the employee or person acting on behalf of |
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the employee and the employee's requesting provider whose |
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reconsideration of an adverse determination is denied to seek |
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review of that determination within the period prescribed by |
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Subsection (b) by an independent review organization assigned in |
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accordance with Chapter 4202 [Article 21.58C] and commissioner |
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rules; and |
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(2) provide to the appropriate independent review |
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organization, not later than the third business day after the date |
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the utilization review agent receives notification of the |
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assignment of the request to an independent review organization: |
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(A) any medical records of the employee that are |
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relevant to the review; |
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(B) any documents used by the utilization review |
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agent in making the determination; |
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(C) the response letter described by Section |
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1305.354(a)(4); |
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(D) any documentation and written information |
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submitted in support of the request for reconsideration; and |
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(E) a list of the providers who provided care to |
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the employee and who may have medical records relevant to the |
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review. |
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(d) The department shall assign the review request to an |
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independent review organization. Notwithstanding Section |
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4202.002, an independent review organization that uses doctors to |
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perform reviews of health care services under this chapter may only |
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use doctors licensed to practice in this state. |
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SECTION 4. The change in law made by this Act applies only |
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to a review of a health care service provided under a claim for |
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workers' compensation benefits that is conducted on or after the |
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effective date of this Act. A review that is conducted before that |
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date is governed by the law in effect on the date that the review was |
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conducted, and the former law is continued in effect for that |
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purpose. |
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SECTION 5. This Act takes effect September 1, 2007. |