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A BILL TO BE ENTITLED
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AN ACT
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relating to prompt payment of health care claims, including payment |
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for immunizations, vaccines, and serums. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter A, Chapter 16, Civil Practice and |
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Remedies Code, is amended by adding Section 16.013 to read as |
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follows: |
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Sec. 16.013. PROMPT PAYMENT OF HEALTH CARE CLAIMS. A person |
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must bring a suit for failure to pay a clean claim in accordance |
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with Subchapter J, Chapter 843, or Subchapter C, Chapter 1301, |
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Insurance Code, not later than two years after the day the cause of |
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action accrues. The cause of action accrues on the latest date |
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provided by the applicable subchapter for determining whether the |
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claim is payable and making the appropriate payment or |
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notification. |
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SECTION 2. Section 843.337(a), Insurance Code, is amended |
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to read as follows: |
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(a) A physician or provider must submit a claim for health |
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care services to a health maintenance organization not later than |
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the 95th day after the date the physician or provider provides the |
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health care services for which the claim is made. A health |
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maintenance organization shall accept as proof of timely filing: |
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(1) a claim filed in compliance with Subsection (e); |
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or |
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(2) information from another health maintenance |
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organization or any insurer authorized or eligible to engage in the |
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business of insurance in this state showing that the physician or |
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provider submitted the claim for health care services to the health |
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maintenance organization or insurer in compliance with Subsection |
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(e). |
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SECTION 3. Sections 843.342(a), (b), (d), and (e), |
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Insurance Code, are amended to read as follows: |
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(a) Except as provided by this section, if a clean claim |
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submitted to a health maintenance organization is payable and the |
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health maintenance organization does not determine under this |
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subchapter that the claim is payable and pay the claim on or before |
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the date the health maintenance organization is required to make a |
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determination or adjudication of the claim, the health maintenance |
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organization shall pay the physician or provider making the claim |
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the contracted rate owed on the claim plus a penalty in the amount |
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of the lesser of: |
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(1) 50 percent of the difference between the billed |
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charges, as submitted on the claim, and the contracted rate; or |
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(2) $5,000 [$100,000]. |
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(b) If the claim is paid on or after the 46th day and before |
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the 91st day after the date the health maintenance organization is |
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required to make a determination or adjudication of the claim, the |
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health maintenance organization shall pay a penalty in the amount |
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of the lesser of: |
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(1) 100 percent of the difference between the billed |
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charges, as submitted on the claim, and the contracted rate; or |
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(2) $10,000 [$200,000]. |
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(d) Except as provided by this section, a health maintenance |
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organization that determines under this subchapter that a claim is |
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payable, pays only a portion of the amount of the claim on or before |
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the date the health maintenance organization is required to make a |
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determination or adjudication of the claim, and pays the balance of |
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the contracted rate owed for the claim after that date shall pay to |
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the physician or provider, in addition to the contracted amount |
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owed, a penalty on the amount not timely paid in the amount of the |
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lesser of: |
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(1) 50 percent of the underpaid amount; or |
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(2) $5,000 [$100,000]. |
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(e) If the balance of the claim is paid on or after the 46th |
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day and before the 91st day after the date the health maintenance |
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organization is required to make a determination or adjudication of |
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the claim, the health maintenance organization shall pay a penalty |
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on the balance of the claim in the amount of the lesser of: |
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(1) 100 percent of the underpaid amount; or |
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(2) $10,000 [$200,000]. |
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SECTION 4. Subchapter J, Chapter 843, Insurance Code, is |
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amended by adding Section 843.3421 to read as follows: |
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Sec. 843.3421. PAYMENT APPEAL DEADLINE. If a contract |
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between a health maintenance organization and a physician or |
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provider directly or indirectly requires that a contractual dispute |
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regarding a post-service payment denial or payment dispute be |
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appealed, the health maintenance organization may not impose a |
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deadline for filing the appeal that is less than 180 days after the |
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earlier of: |
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(1) the date of the initial payment or denial notice; |
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or |
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(2) the latest date for making a payment or |
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notification with respect to the claim under this subchapter. |
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SECTION 5. Subchapter J, Chapter 843, Insurance Code, is |
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amended by adding Section 843.355 to read as follows: |
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Sec. 843.355. PAYMENT FOR IMMUNIZATIONS, VACCINES, AND |
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SERUMS. (a) A contract between a health maintenance organization |
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and a physician or provider must disclose the source of the |
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information used to calculate a fee payment for an immunization, |
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vaccine, or serum. The information must be made readily accessible |
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to the physician or provider, and the contract must include an |
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explanation of how the physician or provider may access the |
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information. |
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(b) Notwithstanding Section 843.321(a)(3), a health |
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maintenance organization is not required to notify a physician or |
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provider, and a contract between a health maintenance organization |
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and a physician or provider may not directly or indirectly require |
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the health maintenance organization to notify the physician or |
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provider, before a change in a fee payment described by Subsection |
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(a) takes effect if the payment change results from a change in |
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information described by Subsection (a), the source of which is a |
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third party not controlled by the health maintenance organization, |
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such as the Centers for Disease Control Vaccine Price List. |
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(c) A contract between a health maintenance organization |
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and a physician or provider must require the health maintenance |
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organization to provide notice of a change of a source of |
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information described by Subsection (a) used to calculate the fee |
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payment for an immunization, vaccine, or serum not later than the |
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90th day before the date the change of source takes effect. |
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SECTION 6. Section 1301.102(c), Insurance Code, is amended |
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to read as follows: |
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(c) An insurer shall accept as proof of timely filing of a |
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claim for medical care or health care services: |
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(1) a claim filed in compliance with Subsection (b); |
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or |
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(2) information from any [another] insurer authorized |
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or eligible to engage in the business of insurance in this state or |
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health maintenance organization showing that the physician or |
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health care provider submitted the claim for medical care or health |
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care services to the insurer or health maintenance organization in |
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compliance with Subsection (b). |
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SECTION 7. Sections 1301.137(a), (b), (d), and (e), |
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Insurance Code, are amended to read as follows: |
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(a) Except as provided by this section, if a clean claim |
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submitted to an insurer is payable and the insurer does not |
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determine under Subchapter C that the claim is payable and pay the |
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claim on or before the date the insurer is required to make a |
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determination or adjudication of the claim, the insurer shall pay |
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the preferred provider making the claim the contracted rate owed on |
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the claim plus a penalty in the amount of the lesser of: |
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(1) 50 percent of the difference between the billed |
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charges, as submitted on the claim, and the contracted rate; or |
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(2) $5,000 [$100,000]. |
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(b) If the claim is paid on or after the 46th day and before |
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the 91st day after the date the insurer is required to make a |
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determination or adjudication of the claim, the insurer shall pay a |
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penalty in the amount of the lesser of: |
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(1) 100 percent of the difference between the billed |
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charges, as submitted on the claim, and the contracted rate; or |
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(2) $10,000 [$200,000]. |
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(d) Except as provided by this section, an insurer that |
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determines under Subchapter C that a claim is payable, pays only a |
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portion of the amount of the claim on or before the date the insurer |
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is required to make a determination or adjudication of the claim, |
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and pays the balance of the contracted rate owed for the claim after |
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that date shall pay to the preferred provider, in addition to the |
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contracted amount owed, a penalty on the amount not timely paid in |
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the amount of the lesser of: |
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(1) 50 percent of the underpaid amount; or |
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(2) $5,000 [$100,000]. |
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(e) If the balance of the claim is paid on or after the 46th |
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day and before the 91st day after the date the insurer is required |
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to make a determination or adjudication of the claim, the insurer |
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shall pay a penalty on the balance of the claim in the amount of the |
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lesser of: |
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(1) 100 percent of the underpaid amount; or |
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(2) $10,000 [$200,000]. |
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SECTION 8. Subchapter C-1, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.1371 to read as follows: |
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Sec. 1301.1371. PAYMENT APPEAL DEADLINE. If a contract |
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between an insurer and a preferred provider directly or indirectly |
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requires that a contractual dispute regarding a post-service |
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payment denial or payment dispute be appealed, the insurer may not |
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impose a deadline for filing the appeal that is less than 180 days |
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after the earlier of: |
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(1) the date of the initial payment or denial notice; |
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or |
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(2) the latest date for making a payment or |
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notification with respect to the claim under Subchapter C. |
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SECTION 9. Subchapter C-1, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.140 to read as follows: |
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Sec. 1301.140. PAYMENT FOR IMMUNIZATIONS, VACCINES, AND |
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SERUMS. (a) A contract between an insurer and a preferred provider |
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must disclose the source of the information used to calculate a fee |
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payment for an immunization, vaccine, or serum. The information |
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must be made readily accessible to the preferred provider, and the |
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contract must include an explanation of how the preferred provider |
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may access the information. |
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(b) Notwithstanding Section 1301.136(a)(3), an insurer is |
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not required to notify a preferred provider, and a contract between |
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an insurer and a preferred provider may not directly or indirectly |
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require the insurer to notify the preferred provider, before a |
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change in a fee payment described by Subsection (a) takes effect if |
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the payment change results from a change in information described |
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by Subsection (a), the source of which is a third party not |
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controlled by the insurer, such as the Centers for Disease Control |
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Vaccine Price List. |
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(c) A contract between an insurer and a preferred provider |
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must require the insurer to provide notice of a change of a source |
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of information described by Subsection (a) used to calculate the |
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fee payment for an immunization, vaccine, or serum not later than |
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the 90th day before the date the change takes effect. |
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SECTION 10. Sections 843.342(m) and 1301.137(l), Insurance |
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Code, are repealed. |
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SECTION 11. It is the intent of the legislature that Section |
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16.013, Civil Practice and Remedies Code, as added by this Act, |
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applies only to a personal cause of action and does not limit or |
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modify the jurisdiction and authority of the commissioner of |
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insurance to enforce the prompt payment requirements of Chapters |
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843 and 1301, Insurance Code. |
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SECTION 12. (a) Section 16.013, Civil Practice and |
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Remedies Code, as added by this Act, applies only to a cause of |
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action arising from a claim submitted on or after the effective date |
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of this Act. A cause of action arising from a claim submitted |
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before the effective date of this Act is governed by the law |
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applicable to the claim immediately before the effective date of |
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this Act, and that law is continued in effect for that purpose. |
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(b) Except as provided by Subsection (c) of this section, |
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Sections 843.337, 843.342, 1301.102, and 1301.137, Insurance Code, |
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as amended by this Act, apply only to a claim submitted on or after |
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the effective date of this Act. A claim submitted before the |
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effective date of this Act is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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(c) With respect to a claim submitted under a contract with |
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a health maintenance organization or insurer, Sections 843.337, |
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843.342, 1301.102, and 1301.137, Insurance Code, as amended by this |
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Act, apply only to a claim submitted under a contract entered into |
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or renewed on or after the effective date of this Act. A claim |
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submitted under a contract entered into or renewed before the |
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effective date of this Act is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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(d) Sections 843.3421, 843.355, 1301.1371, and 1301.140, |
|
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Insurance Code, as added by this Act, apply only to a contract |
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entered into or renewed on or after the effective date of this Act. |
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A contract entered into or renewed before the effective date of this |
|
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Act is governed by the law as it existed immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 13. This Act takes effect September 1, 2015. |