87R6076 JG-D

By: Raymond H.B. No. 1625

A BILL TO BE ENTITLED

AN ACT

relating to a single Internet portal or equivalent electronic system through which Medicaid providers may submit and receive information.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 533.0055, Government Code, is amended by amending Subsection (b) and adding Subsections (c), (d), (e), and (f) to read as follows:

(b) The provider protection plan required under this section must provide for:

(1) prompt payment and proper reimbursement of providers by managed care organizations;

(2) prompt and accurate adjudication of claims through:

(A) provider education on the proper submission of clean claims and on appeals;

(B) acceptance of uniform forms, including HCFA Forms 1500 and UB-92 and subsequent versions of those forms, through an interoperable electronic portal or equivalent electronic system; and

(C) the establishment of standards for claims payments in accordance with a provider's contract;

(3) adequate and clearly defined provider network standards that are specific to provider type, including physicians, general acute care facilities, and other provider types defined in the commission's network adequacy standards in effect on January 1, 2013, and that ensure choice among multiple providers to the greatest extent possible;

(4) a prompt credentialing process for providers;

(5) uniform efficiency standards and requirements for managed care organizations for the submission and tracking of preauthorization requests for services provided under Medicaid;

(6) establishment and maintenance of an interoperable [electronic process, including the use of an] Internet portal or equivalent electronic system with real-time capabilities [,] through which providers in any managed care organization's provider network may:

(A) submit electronic claims, prior authorization requests, claims appeals and reconsiderations, clinical data, and other documentation that the managed care organization requests for prior authorization and claims processing; and

(B) obtain electronic remittance advice, explanation of benefits statements, and other standardized reports;

(7) the measurement of the rates of retention by managed care organizations of significant traditional providers;

(8) the creation of a work group to review and make recommendations to the commission concerning any requirement under this subsection for which immediate implementation is not feasible at the time the plan is otherwise implemented, including the required process for submission and acceptance of attachments for claims processing and prior authorization requests through the Internet portal or equivalent electronic system required by [an electronic process under] Subdivision (6) and, for any requirement that is not implemented immediately, recommendations regarding the expected:

(A) fiscal impact of implementing the requirement; and

(B) timeline for implementation of the requirement; and

(9) any other provision that the commission determines will ensure efficiency or reduce administrative burdens on providers participating in a Medicaid managed care model or arrangement.

(c) The commission, using existing resources, shall consolidate each electronic or Internet portal operated or maintained by the commission for the commission's use, including through a contract with a separate entity, that is used to receive and deliver requests and other information from and to Medicaid providers, including nursing facility providers participating in the STAR+PLUS Medicaid managed care program, into the single Internet portal or equivalent electronic system required by Subsection (b)(6). The commission shall:

(1) ensure the single Internet portal or equivalent electronic system meets the requirements of a portal described by Sections 531.02411, 533.00251, 533.002553, and 533.0071; and

(2) implement a method that allows:

(A) each managed care organization to connect with the single Internet portal or equivalent electronic system; and

(B) a provider to access the single Internet portal or equivalent electronic system both directly and through a managed care organization's Internet website.

(d) The commission may contract with a private or nonprofit entity to develop, operate, and maintain the single Internet portal or equivalent electronic system required by Subsection (b)(6). The entity may not be affiliated with any specific managed care plan.

(e) The executive commissioner by rule shall require each managed care organization to allow providers in the organization's provider network to use the single Internet portal or equivalent electronic system required by Subsection (b)(6).

(f) Notwithstanding any other law, a provider in a managed care organization's provider network may continue to use a provider portal made available by the managed care organization that is interoperable with the single Internet portal or equivalent electronic system, as applicable, required by Subsection (b)(6) instead of accessing the single Internet portal or equivalent electronic system directly.

SECTION 2. Not later than January 1, 2023, the Health and Human Services Commission, or an entity with which the commission contracts, shall develop and implement the single Internet portal or equivalent electronic system required by Section 533.0055, Government Code, as amended by this Act.

SECTION 3. This Act takes effect immediately if it receives a vote of two-thirds of all the members elected to each house, as provided by Section 39, Article III, Texas Constitution. If this Act does not receive the vote necessary for immediate effect, this Act takes effect September 1, 2021.