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A BILL TO BE ENTITLED
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AN ACT
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relating to prompt payment of claims to certain physicians and |
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health care providers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 843.351, Insurance Code, is amended to |
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read as follows: |
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Sec. 843.351. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND |
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PROVIDERS. (a) The provisions of this subchapter relating to prompt |
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payment by a health maintenance organization of a physician or |
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provider, including Section 843.342, and to verification of health |
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care services apply to a physician or provider who: |
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(1) is not included in the health maintenance |
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organization delivery network; and |
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(2) provides to an enrollee: |
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(A) care related to an emergency or its attendant |
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episode of care as required by state or federal law; or |
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(B) specialty or other health care services at |
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the request of the health maintenance organization or a physician |
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or provider who is included in the health maintenance organization |
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delivery network because the services are not reasonably available |
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within the network. |
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(b) For purposes of calculating a penalty under Section |
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843.342 related to a claim by a physician or provider described by |
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Subsection (a), the contracted rate for the health care service |
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provided by the physician or provider is the usual and customary |
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rate for the service in the geographic area in which the service is |
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provided. |
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SECTION 2. Section 1301.069, Insurance Code, is amended to |
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read as follows: |
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Sec. 1301.069. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND |
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HEALTH CARE PROVIDERS. (a) The provisions of this chapter relating |
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to prompt payment by an insurer of a physician or health care |
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provider, including Section 1301.137, and to verification of |
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medical care or health care services apply to a physician or |
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provider who: |
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(1) is not a preferred provider included in the |
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preferred provider network; and |
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(2) provides to an insured: |
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(A) care related to an emergency or its attendant |
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episode of care as required by state or federal law; or |
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(B) specialty or other medical care or health |
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care services at the request of the insurer or a preferred provider |
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because the services are not reasonably available from a preferred |
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provider who is included in the preferred delivery network. |
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(b) For purposes of calculating a penalty under Section |
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1301.137 related to a claim by a physician or health care provider |
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described by Subsection (a) or Section 1301.0053, the contracted |
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rate for the health care service provided by the physician or |
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provider is the usual and customary rate for the service in the |
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geographic area in which the service is provided. |
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SECTION 3. Sections 843.351 and 1301.069, Insurance Code, |
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as amended by this Act, apply only to a claim filed on or after the |
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effective date of this Act. |
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SECTION 4. This Act takes effect September 1, 2019. |