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A BILL TO BE ENTITLED
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AN ACT
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relating to an independent review organization to conduct reviews |
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of certain medical necessity determinations under the Medicaid |
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managed care program. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter A, Chapter 533, Government Code, is |
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amended by adding Section 533.039 to read as follows: |
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Sec. 533.039. INDEPENDENT REVIEW ORGANIZATIONS. (a) In |
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this section, "independent review organization" means an |
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organization certified under Chapter 4202, Insurance Code. |
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(b) The commission shall contract with an independent |
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review organization to make review determinations with respect to |
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disputes at issue in requests for appeal submitted to the |
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commission challenging a medical necessity determination of a |
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managed care organization that contracts with the commission under |
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this chapter, except as provided by Subsection (g). The executive |
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commissioner by rule shall determine: |
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(1) the manner in which an independent review |
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organization is to settle the disputes; |
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(2) when, in the appeals process, an organization may |
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be accessed; and |
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(3) the recourse available after the organization |
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makes a review determination. |
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(c) The commission shall ensure that a contract entered into |
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under Subsection (b): |
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(1) requires an independent review organization to |
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make a review determination in a timely manner; |
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(2) provides procedures to protect the |
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confidentiality of medical records transmitted to the organization |
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for use in conducting an independent review; |
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(3) sets minimum qualifications for and requires the |
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independence of each physician or other health care provider making |
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a review determination on behalf of the organization; |
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(4) specifies the procedures to be used by the |
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organization in making review determinations; |
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(5) requires the timely notice to a recipient of the |
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results of an independent review, including the clinical basis for |
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the review determination; |
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(6) requires that the organization report the |
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following aggregate information to the commission in the form and |
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manner and at the times prescribed by the commission: |
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(A) the number of requests for independent |
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reviews received by the independent review organization; |
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(B) the number of independent reviews conducted; |
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(C) the number of review determinations made: |
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(i) in favor of a managed care |
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organization; and |
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(ii) in favor of a recipient; |
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(D) the number of review determinations that |
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resulted in a managed care organization deciding to cover the |
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service at issue; |
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(E) a summary of the disputes at issue in |
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independent reviews; |
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(F) a summary of the services that were the |
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subject of independent reviews; and |
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(G) the average time the organization took to |
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complete an independent review and make a review determination; and |
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(7) requires that, in addition to the aggregate |
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information required by Subdivision (6), the organization include |
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in the report the information required by that subdivision |
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categorized by managed care organization. |
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(d) An independent review organization with which the |
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commission contracts under this section shall: |
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(1) obtain all information relating to the dispute at |
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issue from the managed care organization and the provider in |
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accordance with time frames prescribed by the commission; |
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(2) assign a physician or other health care provider |
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with appropriate expertise as a reviewer to make a review |
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determination; |
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(3) for each review, perform a check to ensure that the |
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organization and the physician or other health care provider |
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assigned to make a review determination do not have a conflict of |
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interest, as defined in the contract entered into between the |
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commission and the organization; |
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(4) communicate procedural rules, approved by the |
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commission, and other information regarding the appeals process to |
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all parties; and |
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(5) render a timely review determination, as |
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determined by the commission. |
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(e) The commission shall ensure that the managed care |
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organization, the provider, and the recipient involved in a dispute |
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do not have a choice in the reviewer who is assigned to perform the |
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review. |
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(f) In selecting an independent review organization with |
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which to contract, the commission shall avoid conflicts of interest |
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by considering and monitoring existing relationships between |
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independent review organizations and managed care organizations. |
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(g) This section does not apply to, and an independent |
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review organization may not make a review determination with |
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respect to, a dispute involving the commission's office of |
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inspector general or an action taken at the direction of that |
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office, including a dispute relating to: |
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(1) an action taken by a managed care organization at |
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the direction of the office under the lock-in program established |
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in accordance with 42 C.F.R. Part 431.54(e); or |
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(2) the termination or potential termination of a |
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provider's enrollment in a managed care organization's provider |
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network at the direction of the office. |
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(h) The executive commissioner shall adopt rules necessary |
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to implement this section. |
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SECTION 2. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 3. This Act takes effect September 1, 2019. |