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A BILL TO BE ENTITLED
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AN ACT
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relating to a provider protection plan that ensures efficiency and |
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reduces administrative burdens on providers participating in a |
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Medicaid managed care model or arrangement. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter A, Chapter 533, Government Code, is |
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amended by adding Section 533.0055 to read as follows: |
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Sec. 533.0055. PROVIDER PROTECTION PLAN. (a) The |
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commission shall develop and implement a provider protection plan |
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that is designed to reduce administrative burdens placed on |
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providers participating in a Medicaid managed care model or |
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arrangement implemented under this chapter and to ensure efficiency |
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in provider enrollment and reimbursement. The commission shall |
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incorporate the measures identified in the plan, to the greatest |
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extent possible, into each contract between a managed care |
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organization and the commission for the provision of health care |
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services to recipients. |
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(b) The provider protection plan required under this |
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section must provide for: |
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(1) prompt payment and proper reimbursement of |
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providers by managed care organizations; |
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(2) prompt and accurate adjudication of claims |
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through: |
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(A) provider education on the proper submission |
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of clean claims and on appeals; |
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(B) acceptance of uniform forms, including HCFA |
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Forms 1500 and UB-92 and subsequent versions of those forms, |
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through an electronic portal; and |
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(C) the establishment of standards for claims |
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payments in accordance with a provider's contract; |
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(3) adequate and clearly defined provider network |
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standards that are specific to provider type, including physicians, |
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general acute care facilities, and other provider types defined in |
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the commission's network adequacy standards in effect on January 1, |
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2013, and that ensure choice among multiple providers to the |
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greatest extent possible; |
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(4) a prompt credentialing process for providers; |
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(5) uniform efficiency standards and requirements for |
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managed care organizations for the submission and tracking of |
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preauthorization requests for services provided under the Medicaid |
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program; |
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(6) establishment of an electronic process, including |
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the use of an Internet portal, through which providers in any |
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managed care organization's provider network may: |
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(A) submit electronic claims, prior |
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authorization requests, claims appeals and reconsiderations, |
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clinical data, and other documentation that the managed care |
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organization requests for prior authorization and claims |
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processing; and |
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(B) obtain electronic remittance advice, |
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explanation of benefits statements, and other standardized |
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reports; |
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(7) the measurement of the rates of retention by |
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managed care organizations of significant traditional providers; |
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(8) the creation of a work group to review and make |
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recommendations to the commission concerning any requirement under |
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this subsection for which immediate implementation is not feasible |
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at the time the plan is otherwise implemented, including the |
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required process for submission and acceptance of attachments for |
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claims processing and prior authorization requests through an |
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electronic process under Subdivision (6) and, for any requirement |
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that is not implemented immediately, recommendations regarding the |
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expected: |
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(A) fiscal impact of implementing the |
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requirement; and |
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(B) timeline for implementation of the |
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requirement; and |
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(9) any other provision that the commission determines |
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will ensure efficiency or reduce administrative burdens on |
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providers participating in a Medicaid managed care model or |
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arrangement. |
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SECTION 2. As soon as possible, but not later than September |
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1, 2014, the Health and Human Services Commission shall implement |
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the provider protection plan required under Section 533.0055, |
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Government Code, as added by this Act. |
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SECTION 3. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 4. This Act takes effect September 1, 2013. |
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