Amend CSHB 2327 (house committee printing) as follows:

(1)  On page 1, between lines 4 and 5, insert "ARTICLE 1. PREAUTHORIZATION".

(2)  Redesignate SECTIONS 1 through 4 of the bill as ARTICLE 1 of the bill, and renumber those SECTIONS accordingly.

(3)  On page 2, line 20, strike "providing" and substitute "ordering or requesting".

(4)  On page 3, line 23, strike "and" and substitute "or".

(5)  On page 3, line 24, strike "and" and substitute "or".

(6)  On page 4, line 18, between "violation" and the underlined period, insert ", and any health care service affected by the violation is considered preauthorized by the health maintenance organization".

(7)  On page 4, line 23, strike "scope of the".

(8)  On page 4, line 24, strike "license" and substitute "scope of practice as defined by state law".

(9)  On page 4, line 26, strike "scope of a".

(10)  On page 4, line 27, strike "license" and substitute "scope of practice as defined by state law."

(11)  On page 6, line 13, strike "providing" and substitute "ordering or requesting".

(12)  On page 6, line 23, after "provider" insert "type and".

(13)  On page 7, line 20, strike "and" and substitute "or".

(14)  On page 8, line 14, between "violation" and the underlined period, insert ", and any medical care or health care service affected by the violation is considered preauthorized by the insurer".

(15)  On page 8, lines 21 and 22, strike "scope of the".

(16)  On page 8, line 22, strike "license" and substitute "scope of practice as defined by state law".

(17)  On page 8, line 24, strike "scope of a".

(18)  On page 8, line 25, strike "license" and substitute "scope of practice as defined by state law".

(19)  On page 8, after line 27, insert the following:

ARTICLE 2. UTILIZATION, INDEPENDENT, AND PEER REVIEW

SECTION 2.01.  Section 4201.002(12), Insurance Code, is amended to read as follows:

(12)  "Provider of record" means the physician or other health care provider with primary responsibility for the health care[, treatment, and] services provided to or requested on behalf of an enrollee or the physician or other health care provider that has provided or has been requested to provide the health care services to the enrollee. The term includes a health care facility where the health care services are [if treatment is] provided on an inpatient or outpatient basis.

SECTION 2.02.  Sections 4201.151 and 4201.152, Insurance Code, are amended to read as follows:

Sec. 4201.151.  UTILIZATION REVIEW PLAN. A utilization review agent's utilization review plan, including reconsideration and appeal requirements, must be reviewed by a physician licensed to practice medicine in this state and conducted in accordance with standards developed with input from appropriate health care providers and approved by a physician licensed to practice medicine in this state.

Sec. 4201.152.  UTILIZATION REVIEW UNDER [DIRECTION OF] PHYSICIAN. A utilization review agent shall conduct utilization review under the supervision and direction of a physician licensed to practice medicine in this [by a] state [licensing agency in the United States].

SECTION 2.03.  Subchapter D, Chapter 4201, Insurance Code, is amended by adding Section 4201.1525 to read as follows:

SECTION 2.04.  Section 4201.153(d), Insurance Code, is amended to read as follows:

(d)  Screening criteria must be used to determine only whether to approve the requested treatment. Before issuing an adverse determination, a utilization review agent must obtain a determination of medical necessity by referring a proposed [A] denial of requested treatment [must be referred] to:

(1)  an appropriate physician, dentist, or other health care provider; or

(2)  if the treatment is requested, ordered, provided, or to be provided by a physician, a physician licensed to practice medicine in this state who is of the same or a similar specialty as that physician [to determine medical necessity].

SECTION 2.05.  Sections 4201.155, 4201.206, and 4201.251, Insurance Code, are amended to read as follows:

Sec. 4201.155.  LIMITATION ON NOTICE REQUIREMENTS AND REVIEW PROCEDURES. (a) A utilization review agent may not establish or impose a notice requirement or other review procedure that is contrary to the requirements of the health insurance policy or health benefit plan.

Sec. 4201.206.  OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the notice requirements of Subchapter G, before an adverse determination is issued by a utilization review agent who questions the medical necessity, the [or] appropriateness, or the experimental or investigational nature[,] of a health care service, the agent shall provide the health care provider who ordered, requested, provided, or is to provide the service a reasonable opportunity to discuss with a physician licensed to practice medicine in this state the patient's treatment plan and the clinical basis for the agent's determination.

Sec. 4201.251.  DELEGATION OF UTILIZATION REVIEW. A utilization review agent may delegate utilization review to qualified personnel in the hospital or other health care facility in which the health care services to be reviewed were or are to be provided. The delegation does not release the agent from the full responsibility for compliance with this chapter or other applicable law, including the conduct of those to whom utilization review has been delegated.

SECTION 2.06.  Sections 4201.252(a) and (b), Insurance Code, are amended to read as follows:

(a)  Personnel employed by or under contract with a utilization review agent to perform utilization review must be appropriately trained and qualified and meet the requirements of this chapter and other applicable law, including licensing requirements.

(b)  Personnel, other than a physician licensed to practice medicine in this state, who obtain oral or written information directly from a patient's physician or other health care provider regarding the patient's specific medical condition, diagnosis, or treatment options or protocols must be a nurse, physician assistant, or other health care provider qualified and licensed or otherwise authorized by law and the appropriate licensing agency in this state to provide the requested service.

SECTION 2.07.  Section 4201.356, Insurance Code, is amended to read as follows:

Sec. 4201.356.  DECISION BY PHYSICIAN REQUIRED; SPECIALTY REVIEW. (a) The procedures for appealing an adverse determination must provide that a physician licensed to practice medicine in this state makes the decision on the appeal, except as provided by Subsection (b) or (c).

(b)  For a health care service ordered, requested, provided, or to be provided by a physician, the procedures for appealing an adverse determination must provide that a physician licensed to practice medicine in this state who is of the same or a similar specialty as that physician makes the decision on appeal, except as provided by Subsection (c).

(c)  If not later than the 10th working day after the date an appeal is denied the enrollee's health care provider states in writing good cause for having a particular type of specialty provider review the case, a health care provider who is of the same or a similar specialty as the health care provider who would typically manage the medical or dental condition, procedure, or treatment under consideration for review and who is licensed or otherwise authorized by the appropriate licensing agency in this state to manage the medical or dental condition, procedure, or treatment shall review the decision denying the appeal. The specialty review must be completed within 15 working days of the date the health care provider's request for specialty review is received.

SECTION 2.08.  Sections 4201.357(a), (a-1), and (a-2), Insurance Code, are amended to read as follows:

(a)  The procedures for appealing an adverse determination must include, in addition to the written appeal, a procedure for an expedited appeal of a denial of emergency care or a denial of continued hospitalization. That procedure must include a review by a health care provider who:

(1)  has not previously reviewed the case; [and]

(2)  is of the same or a similar specialty as the health care provider who would typically manage the medical or dental condition, procedure, or treatment under review in the appeal; and

(B)  ordered, requested, provided, or to be provided by a physician, is licensed to practice medicine in this state.

(a-1)  The procedures for appealing an adverse determination must include, in addition to the written appeal and the appeal described by Subsection (a), a procedure for an expedited appeal of a denial of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy. That procedure must include a review by a health care provider who:

(1)  has not previously reviewed the case; [and]

(2)  is of the same or a similar specialty as the health care provider who would typically manage the medical or dental condition, procedure, or treatment under review in the appeal; and

(B)  ordered, requested, provided, or to be provided by a physician, is licensed to practice medicine in this state.

(a-2)  An adverse determination under Section 1369.0546 is entitled to an expedited appeal. The physician or, if appropriate, other health care provider deciding the appeal must consider atypical diagnoses and the needs of atypical patient populations. The physician must be licensed to practice medicine in this state and the health care provider must be licensed or otherwise authorized by the appropriate licensing agency in this state.

SECTION 2.09.  Section 4201.359, Insurance Code, is amended by adding Subsection (c) to read as follows:

SECTION 2.10.  Sections 4201.453 and 4201.454, Insurance Code, are amended to read as follows:

Sec. 4201.453.  UTILIZATION REVIEW PLAN. A specialty utilization review agent's utilization review plan, including reconsideration and appeal requirements, must be:

(1)  reviewed by a health care provider of the appropriate specialty who is licensed or otherwise authorized to provide the specialty health care service in this state; and

(2)  conducted in accordance with standards developed with input from a health care provider of the appropriate specialty who is licensed or otherwise authorized to provide the specialty health care service in this state.

Sec. 4201.454.  UTILIZATION REVIEW UNDER DIRECTION OF PROVIDER OF SAME SPECIALTY. A specialty utilization review agent shall conduct utilization review under the direction of a health care provider who is of the same specialty as the agent and who is licensed or otherwise authorized to provide the specialty health care service in this [by a] state [licensing agency in the United States].

SECTION 2.11.  Sections 4201.455(a) and (b), Insurance Code, are amended to read as follows:

(a)  Personnel who are employed by or under contract with a specialty utilization review agent to perform utilization review must be appropriately trained and qualified and meet the requirements of this chapter and other applicable law of this state, including licensing laws.

(b)  Personnel who obtain oral or written information directly from a physician or other health care provider must be a nurse, physician assistant, or other health care provider of the same specialty as the agent and who are licensed or otherwise authorized to provide the specialty health care service in this [by a] state [licensing agency in the United States].

SECTION 2.12.  Sections 4201.456 and 4201.457, Insurance Code, are amended to read as follows:

Sec. 4201.456.  OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE DETERMINATION. Subject to the notice requirements of Subchapter G, before an adverse determination is issued by a specialty utilization review agent who questions the medical necessity, the [or] appropriateness, or the experimental or investigational nature[,] of a health care service, the agent shall provide the health care provider who ordered, requested, provided, or is to provide the service a reasonable opportunity to discuss the patient's treatment plan and the clinical basis for the agent's determination with a health care provider who is:

(1)  of the same specialty as the agent; and

(2)  licensed or otherwise authorized to provide the specialty health care service in this state.

Sec. 4201.457.  APPEAL DECISIONS. A specialty utilization review agent shall comply with the requirement that a physician or other health care provider who makes the decision in an appeal of an adverse determination must be:

(1)  of the same or a similar specialty as the health care provider who would typically manage the specialty condition, procedure, or treatment under review in the appeal; and

(2)  licensed or otherwise authorized to provide the health care service in this state.

SECTION 2.13.  Section 4202.002, Insurance Code, is amended by adding Subsection (b-1) to read as follows:

SECTION 2.14.  Section 408.0043, Labor Code, is amended by adding Subsection (c) to read as follows:

SECTION 2.15.  Subchapter B, Chapter 151, Occupations Code, is amended by adding Section 151.057 to read as follows:

SECTION 2.16.  Section 1305.351(d), Insurance Code, is amended to read as follows:

(d)  A [Notwithstanding Section 4201.152, a] utilization review agent or an insurance carrier that uses doctors to perform reviews of health care services provided under this chapter, including utilization review, or peer reviews under Section 408.0231(g), Labor Code, may only use doctors licensed to practice in this state.

SECTION 2.17.  Section 1305.355(d), Insurance Code, is amended to read as follows:

(d)  The department shall assign the review request to an independent review organization.  An [Notwithstanding Section 4202.002, an] independent review organization that uses doctors to perform reviews of health care services under this chapter may only use doctors licensed to practice in this state.

SECTION 2.18.  Section 408.023(h), Labor Code, is amended to read as follows:

(h)  A [Notwithstanding Section 4201.152, Insurance Code, a] utilization review agent or an insurance carrier that uses doctors to perform reviews of health care services provided under this subtitle, including utilization review, may only use doctors licensed to practice in this state.

SECTION 2.19.  Section 413.031(e-2), Labor Code, is amended to read as follows:

(e-2)  An [Notwithstanding Section 4202.002, Insurance Code, an] independent review organization that uses doctors to perform reviews of health care services provided under this title may only use doctors licensed to practice in this state.

ARTICLE 3. TRANSITIONS; EFFECTIVE DATE

(20)  On page 9, strike line 1 and substitute the following:

SECTION 3.01.  The changes in law made by Article 1 of this Act apply only

(21)  On page 9, strike line 11 and substitute the following:

SECTION 3.02.  The changes in law made by Article 2 of this Act apply only to utilization, independent, or peer review requested on or after the effective date of this Act. Utilization, independent, or peer review requested before the effective date of this Act is governed by the law as it existed immediately before the effective date of this Act, and that law is continued in effect for that purpose.

SECTION 3.03.  This Act takes effect September 1, 2019.