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A BILL TO BE ENTITLED
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AN ACT
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relating to certain payment recovery efforts by managed care |
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organizations under Medicaid or the child health plan program. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 531.1131, Government Code, is amended by |
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amending Subsection (f) and adding Subsection (g) to read as |
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follows: |
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(f) In adopting rules establishing due process procedures |
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under Subsection (e), the executive commissioner shall require that |
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a managed care organization or an entity with which the managed care |
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organization contracts under Section 531.113(a)(2) that engages in |
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payment recovery efforts in accordance with this section and |
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Section 531.1135 provide: |
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(1) written notice to a provider required to use |
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electronic visit verification of the organization's intent to |
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recoup overpayments in accordance with Section 531.1135; and |
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(2) any [a] provider [described by Subdivision (1)] at |
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least 60 days after the provider has exhausted all rights to an |
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appeal to cure any defect in a claim, including by submitting |
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necessary documentation for the claim or resubmitting the claim, |
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before the organization may begin any efforts to collect |
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overpayments. |
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(g) A managed care organization or an entity with which the |
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managed care organization contracts under Section 531.113(a)(2) |
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that engages in payment recovery efforts under this section or |
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Section 531.1135, in conducting an audit or other review of a claim |
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for which the organization granted prior authorization, may not |
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review: |
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(1) the medical necessity determination; or |
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(2) an error in the claim documentation, if the error |
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was not made by the provider. |
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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, 2023. |