82R20074 AJA-F
 
  By: Hunter, Hopson H.B. No. 2292
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to payment of claims to pharmacies and pharmacists.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 843.002, Insurance Code, is amended by
  amending Subdivision (9-a) and adding Subdivision (9-b) to read as
  follows:
               (9-a)  "Extrapolation" means a mathematical process or
  technique used by a health maintenance organization or pharmacy
  benefit manager that administers pharmacy claims for a health
  maintenance organization in the audit of a pharmacy or pharmacist
  to estimate audit results or findings for a larger batch or group of
  claims not reviewed by the health maintenance organization or
  pharmacy benefit manager.
               (9-b) "Freestanding emergency medical care facility"
  means a facility licensed under Chapter 254, Health and Safety
  Code.
         SECTION 2.  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.
         SECTION 3.  Section 843.339, Insurance Code, is amended to
  read as follows:
         Sec. 843.339.  DEADLINE FOR ACTION ON [CERTAIN] PRESCRIPTION
  CLAIMS; PAYMENT. (a)  A [Not later than the 21st day after the date
  a] health maintenance organization, or a pharmacy benefit manager
  that administers pharmacy claims for the health maintenance
  organization, that affirmatively adjudicates a pharmacy claim that
  is electronically submitted[, the health maintenance organization]
  shall pay the total amount of the claim through electronic funds
  transfer not later than the 18th day after the date on which the
  claim was affirmatively adjudicated.
         (b)  A health maintenance organization, or a pharmacy
  benefit manager that administers pharmacy claims for the health
  maintenance organization, that affirmatively adjudicates a
  pharmacy claim that is not electronically submitted shall pay the
  total amount of the claim not later than the 21st day after the date
  on which the claim was affirmatively adjudicated.
         SECTION 4.  Subchapter J, Chapter 843, Insurance Code, is
  amended by adding Section 843.3401 to read as follows:
         Sec. 843.3401.  AUDIT OF PHARMACIST OR PHARMACY.  (a)  A
  health maintenance organization or a pharmacy benefit manager that
  administers pharmacy claims for the health maintenance
  organization may not use extrapolation to complete the audit of a
  provider who is a pharmacist or pharmacy. A health maintenance
  organization may not require extrapolation audits as a condition of
  participation in the health maintenance organization's contract,
  network, or program for a provider who is a pharmacist or pharmacy.
         (b)  A health maintenance organization or a pharmacy benefit
  manager that administers pharmacy claims for the health maintenance
  organization that performs an on-site audit under this chapter of a
  provider who is a pharmacist or pharmacy shall provide the provider
  reasonable notice of the audit and accommodate the provider's
  schedule to the greatest extent possible. The notice required
  under this subsection must be in writing and must be sent by
  certified mail to the provider not later than the 15th day before
  the date on which the on-site audit is scheduled to occur.
         SECTION 5.  Section 843.344, Insurance Code, is amended to
  read as follows:
         Sec. 843.344.  APPLICABILITY OF SUBCHAPTER TO ENTITIES
  CONTRACTING WITH HEALTH MAINTENANCE ORGANIZATION. This subchapter
  applies to a person, including a pharmacy benefit manager, with
  whom a health maintenance organization contracts to:
               (1)  process or pay claims;
               (2)  obtain the services of physicians and providers to
  provide health care services to enrollees; or
               (3)  issue verifications or preauthorizations.
         SECTION 6.  Subchapter J, Chapter 843, Insurance Code, is
  amended by adding Section 843.354 to read as follows:
         Sec. 843.354.  LEGISLATIVE DECLARATION. It is the intent of
  the legislature that the requirements contained in this subchapter
  regarding payment of claims to providers who are pharmacists or
  pharmacies apply to all health maintenance organizations and
  pharmacy benefit managers unless otherwise prohibited by federal
  law.
         SECTION 7.  Section 1301.001, Insurance Code, is amended by
  amending Subdivision (1) and adding Subdivision (1-a) to read as
  follows:
               (1)  "Extrapolation" means a mathematical process or
  technique used by an insurer or pharmacy benefit manager that
  administers pharmacy claims for an insurer in the audit of a
  pharmacy or pharmacist to estimate audit results or findings for a
  larger batch or group of claims not reviewed by the insurer or
  pharmacy benefit manager.
               (1-a)  "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.
         SECTION 8.  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.
         SECTION 9.  Section 1301.104, Insurance Code, is amended to
  read as follows:
         Sec. 1301.104.  DEADLINE FOR ACTION ON [CERTAIN] PHARMACY
  CLAIMS; PAYMENT.  (a) An  [Not later than the 21st day after the date
  an] insurer, or a pharmacy benefit manager that administers
  pharmacy claims for the insurer under a preferred provider benefit
  plan, that affirmatively adjudicates a pharmacy claim that is
  electronically submitted[, the insurer] shall pay the total amount
  of the claim through electronic funds transfer not later than the
  18th day after the date on which the claim was affirmatively
  adjudicated.
         (b)  An insurer, or a pharmacy benefit manager that
  administers pharmacy claims for the insurer under a preferred
  provider benefit plan, that affirmatively adjudicates a pharmacy
  claim that is not electronically submitted shall pay the total
  amount of the claim not later than the 21st day after the date on
  which the claim was affirmatively adjudicated.
         SECTION 10.  Subchapter C, Chapter 1301, Insurance Code, is
  amended by adding Section 1301.1041 to read as follows:
         Sec. 1301.1041.  AUDIT OF PHARMACIST OR PHARMACY.  (a)  An
  insurer or a pharmacy benefit manager that administers pharmacy
  claims for the insurer may not use extrapolation to complete the
  audit of a preferred provider that is a pharmacist or pharmacy. An
  insurer may not require extrapolation audits as a condition of
  participation in the insurer's contract, network, or program for a
  preferred provider that is a pharmacist or pharmacy.
         (b)  An insurer or a pharmacy benefit manager that
  administers pharmacy claims for the insurer that performs an
  on-site audit of a preferred provider who is a pharmacist or
  pharmacy shall provide the provider reasonable notice of the audit
  and accommodate the provider's schedule to the greatest extent
  possible. The notice required under this subsection must be in
  writing and must be sent by certified mail to the preferred provider
  not later than the 15th day before the date on which the on-site
  audit is scheduled to occur.
         SECTION 11.  Section 1301.109, Insurance Code, is amended to
  read as follows:
         Sec. 1301.109.  APPLICABILITY TO ENTITIES CONTRACTING WITH
  INSURER. This subchapter applies to a person, including a pharmacy
  benefit manager, with whom an insurer contracts to:
               (1)  process or pay claims;
               (2)  obtain the services of physicians and health care
  providers to provide health care services to insureds; or
               (3)  issue verifications or preauthorizations.
         SECTION 12.  Subchapter C-1, Chapter 1301, Insurance Code,
  is amended by adding Section 1301.139 to read as follows:
         Sec. 1301.139.  LEGISLATIVE DECLARATION. It is the intent
  of the legislature that the requirements contained in this
  subchapter regarding payment of claims to preferred providers who
  are pharmacists or pharmacies apply to all insurers and pharmacy
  benefit managers unless otherwise prohibited by federal law.
         SECTION 13.  (a)  With respect to pharmacy benefits provided
  under a contract, the changes in law made by this Act apply only to a
  contract entered into or renewed on or after the effective date of
  this Act and payment for pharmacy benefits provided under the
  contract. A contract entered into before the effective date of this
  Act and not renewed or that was last renewed before the effective
  date of this Act, and payment for pharmacy benefits provided under
  the contract, are governed by the law in effect immediately before
  the effective date of this Act, and that law is continued in effect
  for that purpose.
         (b)  With respect to payment for pharmacy benefits not
  provided under a contract to which Subsection (a) of this section
  applies, the changes in law made by this Act apply only to payment
  for benefits provided on or after the effective date of this Act.
  Payment for benefits not subject to Subsection (a) of this section
  and provided before the effective date of this Act 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.
         (c)  Sections 843.3401 and 1301.1041, Insurance Code, as
  added by this Act, apply to an audit of a pharmacist or pharmacy
  performed on or after the effective date of this Act unless the
  audit is performed under a contract that is entered into before the
  effective date of this Act and that, at the time of the audit, has
  not been renewed or was last renewed before the effective date of
  this Act.
         SECTION 14.  This Act takes effect September 1, 2011.