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A BILL TO BE ENTITLED
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AN ACT
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relating to claims submitted and requests for verification made by |
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a physician or health care provider to certain health benefit plan |
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issuers and administrators. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 843.3385, Insurance Code, is amended by |
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adding Subsection (g) to read as follows: |
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(g) A health maintenance organization shall accept relevant |
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clinical records submitted by a treating physician or provider with |
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a claim related to the records or at any time after submission of |
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the claim. |
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SECTION 2. Section 843.342, Insurance Code, is amended by |
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adding Subsection (o) to read as follows: |
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(o) For the purposes of calculating a penalty under this |
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section related to a claim by a physician or provider described by |
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Section 843.351, the contracted rate for health care services |
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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 3. 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. 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 and to verification of health care services apply to a |
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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 health care services to an enrollee[: |
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[(A) care related to an emergency or its |
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attendant 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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SECTION 4. 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. The provisions of this chapter relating to |
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prompt payment by an insurer of a physician or health care provider |
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and to verification of medical care or health care services apply to |
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a physician or 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 health care services to an insured[: |
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[(A) care related to an emergency or its |
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attendant 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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SECTION 5. Section 1301.1054, Insurance Code, is amended by |
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adding Subsection (f) to read as follows: |
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(f) An insurer shall accept relevant clinical records |
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submitted by a treating physician or provider with a claim related |
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to the records or at any time after submission of the claim. |
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SECTION 6. Section 1301.137, Insurance Code, is amended by |
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adding Subsection (m) to read as follows: |
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(m) For the purposes of calculating a penalty under this |
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section related to a claim by a physician or health care provider |
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described by Section 1301.069, the contracted rate for health care |
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services provided by the physician or provider is the usual and |
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customary rate for the service in the geographic area in which the |
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service is provided. |
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SECTION 7. Subchapter E, Chapter 1551, Insurance Code, is |
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amended by adding Section 1551.231 to read as follows: |
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Sec. 1551.231. ACCEPTANCE OF CLINICAL RECORDS. The |
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administrator of a managed care plan provided under the group |
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benefits program shall accept relevant clinical records submitted |
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by a treating physician or provider with a claim related to the |
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records or at any time after submission of the claim. |
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SECTION 8. Subchapter D, Chapter 1575, Insurance Code, is |
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amended by adding Section 1575.174 to read as follows: |
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Sec. 1575.174. ACCEPTANCE OF CLINICAL RECORDS. The |
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administrator of a managed care plan provided under the group |
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program shall accept relevant clinical records submitted by a |
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treating physician or provider with a claim related to the records |
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or at any time after submission of the claim. |
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SECTION 9. Subchapter C, Chapter 1579, Insurance Code, is |
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amended by adding Section 1579.112 to read as follows: |
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Sec. 1579.112. ACCEPTANCE OF CLINICAL RECORDS. The |
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administrator of a managed care plan provided under this chapter |
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shall accept relevant clinical records submitted by a treating |
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physician or provider with a claim related to the records or at any |
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time after submission of the claim. |
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SECTION 10. Subchapter D, Chapter 1601, Insurance Code, is |
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amended by adding Section 1601.156 to read as follows: |
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Sec. 1601.156. ACCEPTANCE OF CLINICAL RECORDS. The |
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administering carrier of a managed care plan provided under this |
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chapter shall accept relevant clinical records submitted by a |
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treating physician or provider with a claim related to the records |
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or at any time after submission of the claim. |
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SECTION 11. (a) Sections 843.342(o) and 1301.137(m), |
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Insurance Code, as added by this Act, apply only to a penalty or |
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interest on a penalty owed with respect to a claim submitted on or |
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after the effective date of this Act. |
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(b) Sections 843.351 and 1301.069, Insurance Code, as |
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amended by this Act, apply only to health care services provided and |
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verification requests made on or after the effective date of this |
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Act. Health care services provided and verification requests made |
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before the effective date of this Act are governed by the law as it |
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existed immediately before the effective date of this Act, and that |
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law is continued in effect for that purpose. |
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SECTION 12. This Act takes effect September 1, 2023. |