By: Buckingham S.B. No. 1883
 
 
 
   
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to preauthorization and utilization review for certain
  health benefit plans.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subchapter J, Chapter 843, Insurance Code is
  amended by adding Section 843.3483 to read as follows:
         Sec. 843.3483.  EXEMPTION FROM PREAUTHORIZATION
  REQUIREMENTS. (a) A health maintenance organization that uses a
  preauthorization process for health care services may not require a
  physician or provider to obtain preauthorization for a particular
  health care service if, in the preceding calendar year, the
  physician or provider had at least eighty percent of the
  physician's or provider's preauthorization requests approved by the
  health maintenance organization for that health care service.
         (b)  Each exemption from preauthorization requirements
  described by Subsection (a) shall last for one calendar year and is
  only available for a health care service for which the physician or
  provider submitted at least five preauthorization requests in the
  preceding calendar year.
         (c)  A health maintenance organization shall notify each
  physician or provider who qualifies for an exemption from
  preauthorization requirements under Subsection (a) of the
  physician's or provider's exempt status, including the health care
  services for which the exemption applies and the exemption start
  and end date.
         (d)  If a physician or provider submits a preauthorization
  request for a health care service for which an exemption applies
  under Subsection (a), the health maintenance organization shall
  promptly notify the physician or provider of the applicable
  exemption, the calendar year and health care services for which the
  exemption applies, and the health maintenance organization payment
  requirements under Subsection (e).
         (e)  If a preauthorization exemption applies to a health care
  service under Subsection (a), a health maintenance organization may
  not deny or reduce payment to the physician or provider for the
  health care service based on medical necessity or appropriateness
  of care.
         SECTION 2.  Subchapter C-1, Chapter 1301, Insurance Code is
  amended by adding Section 1301.1354 to read as follows:
         Sec. 1301.1354.  EXEMPTION FROM PREAUTHORIZATION
  REQUIREMENTS. (a) An insurer that uses a preauthorization process
  for medical care or health care services may not require a physician
  or health care provider to obtain preauthorization for a particular
  medical care or health care service if, in the preceding calendar
  year, the physician or health care provider had at least eighty
  percent of the physician's or health care provider's
  preauthorization requests approved by the insurer for that medical
  care or health care service.
         (b)  Each exemption from preauthorization requirements
  described by Subsection (a) shall last for one calendar year and is
  only available for a medical care or health care service for which
  the physician or health care provider submitted at least five
  preauthorization requests in the preceding calendar year.
         (c)  An insurer shall notify each physician or health care
  provider who qualifies for an exemption from preauthorization
  requirements under Subsection (a) of the physician's or health care
  provider's exempt status, including the medical care or health care
  services for which the exemption applies and the exemption start
  and end date.
         (d)  If a physician or health care provider submits a
  preauthorization request for a medical care or health care service
  for which an exemption applies under Subsection (a), the insurer
  shall promptly notify the physician or health care provider of the
  applicable exemption, the calendar year and medical care or health
  care services for which the exemption applies, and the insurer
  payment requirements under Subsection (e).
         (e)  If a preauthorization exemption applies to a medical
  care or health care service under Subsection (a), an insurer may not
  deny or reduce payment to the physician or health care provider for
  the medical care or health care service based on medical necessity
  or appropriateness of care.
         SECTION 3.  Section 4201.206, Insurance Code, is amended to
  read as follows:
         Sec. 4201.206.  OPPORTUNITY TO DISCUSS TREATMENT BEFORE
  ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the
  notice requirements of Subchapter G, before an adverse
  determination is issued by a utilization review agent who questions
  the medical necessity, the appropriateness, or the experimental or
  investigational nature of a health care service, the agent shall
  provide the health care provider who ordered, requested, provided,
  or is to provide the service a reasonable opportunity to discuss
  with a physician licensed to practice medicine in this state the
  patient's treatment plan and the clinical basis for the agent's
  determination.
         (b)  If the health care service described by Subsection (a)
  was ordered, requested, or provided, or is to be provided by a
  physician, the opportunity described by that subsection must be
  with a physician licensed to practice medicine in this state who is
  of the same or similar specialty as that physician.
         SECTION 4.  The changes in law made by this Act to Section
  4201.206, Insurance Code, apply only to utilization review
  requested on or after the effective date of this Act. Utilization
  review requested before the effective date of this Act is governed
  by the law as it existed immediately before the effective date of
  this Act, and that law is continued in effect for that purpose.
         SECTION 5.  This Act takes effect September 1, 2021.