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A BILL TO BE ENTITLED
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AN ACT
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relating to review of the medical necessity of certain health care |
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provided in connection with a workers' compensation claim. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter B, Chapter 413, Labor Code, is |
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amended by adding Section 413.0142 to read as follows: |
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Sec. 413.0142. WAIVER OF CERTAIN INSURER CHALLENGES. (a) |
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Regarding a specific treatment or service approved in the |
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preauthorization process, an insurance carrier waives the right to |
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raise a future challenge alleging that an injury sustained by an |
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injured employee is not compensable or that health care provided to |
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an injured employee was not related to a compensable injury if: |
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(1) the insurance carrier does not include the |
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compensability of the injury or that the health care provided to the |
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injured employee was not related to a compensable injury as a basis |
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for an initial denial of a request for preauthorization or the |
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denial of reconsideration of coverage; and |
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(2) the requested treatment or service is ultimately |
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determined through a medical dispute resolution proceeding to be |
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health care reasonably required under this subtitle. |
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(b) This section may not be construed as limiting an |
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insurance carrier's ability to challenge compensability or the |
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relatedness to a compensable injury of provided health care if the |
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challenge concerns income benefits or medical benefits not included |
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in the preauthorization request. |
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(c) If the insurance carrier raises a compensability or |
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relatedness issue in a denial of preauthorization, that issue must |
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be considered and resolved in the same proceeding that addresses |
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the issue of whether the requested treatment or service is health |
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care reasonably required under this subtitle. |
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SECTION 2. Section 413.031(d), Labor Code, is amended 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, Insurance Code, in the same manner as reviews of utilization |
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review decisions by health maintenance organizations. The |
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independent review organization's decision is limited to whether |
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the proposed treatment or service is health care reasonably |
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required for the injury. The independent review organization may |
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not consider issues relating to allegations as to whether the |
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injury in question is compensable or that the health care provided |
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to the injured employee was not related to the compensable injury. |
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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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SECTION 3. The change in law made by this Act applies only |
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to a claim for workers' compensation benefits based on a |
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compensable injury that occurs on or after the effective date of |
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this Act. A claim based on a compensable injury that occurs before |
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that date is governed by the law in effect on the date the |
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compensable injury occurred, and the former law is continued in |
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effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2009. |