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A BILL TO BE ENTITLED
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AN ACT
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relating to denial of payment for preauthorized health care or |
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dental care services. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 843.348, Insurance Code, is amended by |
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adding Subsection (g-1) to read as follows: |
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(g-1) Nothing in Subsection (g) may be construed to: |
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(1) authorize a provider to provide health care |
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services outside of the scope of the provider's practice as defined |
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by applicable state law; or |
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(2) require the health maintenance organization to pay |
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for a health care service provided outside of the scope of a |
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provider's practice as defined by applicable state law. |
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SECTION 2. The heading to Chapter 1217, Insurance Code, is |
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amended to read as follows: |
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CHAPTER 1217. [STANDARD REQUEST FORM FOR] PRIOR AUTHORIZATION OF |
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HEALTH CARE OR DENTAL CARE SERVICES |
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SECTION 3. Chapter 1217, Insurance Code, is amended by |
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adding Section 1217.008 to read as follows: |
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Sec. 1217.008. PROHIBITION OF DENIAL OF PAYMENT FOR |
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PREAUTHORIZED HEALTH CARE OR DENTAL CARE SERVICES. (a) If a health |
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benefit plan issuer has given prior authorization for health care |
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or dental care services, the health benefit plan issuer may not deny |
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or reduce payment to the physician, dentist, or health care |
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provider for those services based on medical necessity or |
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appropriateness of care unless the physician, dentist, or health |
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care provider materially misrepresented the proposed health care or |
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dental care services or substantially failed to perform the |
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proposed health care or dental care services. |
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(b) Nothing in this section limits the liability of a |
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physician, dentist, or health care provider: |
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(1) in an action brought under Chapter 36, Human |
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Resources Code; or |
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(2) for a violation of state or federal law governing |
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medical assistance under Chapter 32, Human Resources Code, |
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including medical assistance delivered through a managed care model |
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or health benefits provided under the state child health plan |
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program under Chapter 62, Health and Safety Code. |
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(c) Subsection (a) does not apply to: |
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(1) a denial, recoupment, or suspension of or |
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reduction in a payment to a physician, dentist, or health care |
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provider made by a managed care organization under the direction of |
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the Health and Human Services Commission's office of the inspector |
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general, under the office's authority to prevent, detect, audit, |
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inspect, review, and investigate fraud, waste, and abuse in the |
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provision and delivery of all health and human services in the state |
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under Section 531.102, Government Code; or |
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(2) a recovery by a managed care organization under |
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Section 531.1131, Government Code. |
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(d) Nothing in Subsection (a) may be construed to: |
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(1) authorize a health care provider to provide health |
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care services outside of the scope of the health care provider's |
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practice as defined by applicable state law; or |
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(2) require the health benefit plan issuer to pay for a |
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health care service provided outside of the scope of a health care |
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provider's practice as defined by applicable state law. |
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SECTION 4. Section 1301.135, Insurance Code, is amended by |
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adding Subsection (f-1) to read as follows: |
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(f-1) Nothing in Subsection (f) may be construed to: |
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(1) authorize a health care provider to provide |
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medical care or health care services outside of the scope of the |
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health care provider's practice as defined by applicable state law; |
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or |
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(2) require the insurer to pay for a medical care or |
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health care service provided outside of the scope of a health care |
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provider's practice as defined by applicable state law. |
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SECTION 5. This Act takes effect September 1, 2019. |