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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 |
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services. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. 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 SERVICES |
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SECTION 2. 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 SERVICES. (a) If a health benefit plan |
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issuer has given prior authorization for health care services to be |
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performed by a physician or health care provider, the health |
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benefit plan issuer may not deny or reduce payment to the physician |
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or health care provider for those services based on medical |
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necessity or appropriateness of care unless the physician or health |
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care provider materially misrepresented the proposed health care |
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services or substantially failed to perform the proposed health |
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care services. |
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(b) Nothing in this section limits the liability of a |
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physician 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 or health care provider made |
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by a managed care organization under the direction of the Health and |
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Human Services Commission's office of the inspector general, under |
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the office's authority to prevent, detect, audit, inspect, review, |
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and investigate fraud, waste, and abuse in the provision and |
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delivery of all health and human services in the state under Section |
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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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SECTION 3. This Act takes effect September 1, 2019. |