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A BILL TO BE ENTITLED
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AN ACT
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relating to laboratory claim integrity programs for health benefit |
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plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle A, Title 8, Insurance Code, is amended |
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by adding Chapter 1224 to read as follows: |
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CHAPTER 1224. LABORATORY CLAIM INTEGRITY PROGRAMS |
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Sec. 1224.001. DEFINITIONS. In this chapter: |
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(1) "Clinical laboratory test" means the examination |
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of a sample of biological material taken from a human body ordered |
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by a physician or health care provider for use in the diagnosis, |
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prevention, or treatment of a disease or the identification or |
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assessment of a medical or physical condition. |
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(2) "Enrollee" means an individual enrolled in a |
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health benefit plan. |
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(3) "Health benefit plan issuer" means an entity |
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authorized under this code or another insurance law of this state to |
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provide benefits for health care services, including: |
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(A) an insurance company; |
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(B) a group hospital service corporation |
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operating under Chapter 842; |
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(C) a health maintenance organization operating |
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under Chapter 843; |
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(D) an approved nonprofit health corporation |
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that holds a certificate of authority under Chapter 844; |
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(E) a multiple employer welfare arrangement that |
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holds a certificate of authority under Chapter 846; or |
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(F) a fraternal benefit society operating under |
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Chapter 885. |
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(4) "Laboratory claim integrity program" means a claim |
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editing program that identifies wasteful clinical laboratory tests |
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based on the health benefit plan's clinical laboratory testing |
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reimbursement policies. |
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(5) "Person" means an individual, corporation, trust, |
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partnership, association, or any other legal entity. |
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Sec. 1224.002. REGISTRATION FOR PERSON PROVIDING |
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LABORATORY CLAIM INTEGRITY PROGRAM. (a) A person shall register |
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with the department before providing a laboratory claim integrity |
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program in this state. The registration is valid for three years and |
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may be renewed. |
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(b) The commissioner shall promulgate a form to be submitted |
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under this section for the initial registration and renewal of a |
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registration. The form for initial registration must include: |
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(1) the name, address, telephone number, and e-mail |
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address of the applicant; |
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(2) the name and address of an agent for service of |
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process in this state; and |
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(3) a summary of the laboratory claim integrity |
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program. |
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(c) Upon request by the commissioner, a person registered |
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under this section shall identify each health benefit plan issuer |
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who has contracted with the person for the provision of a laboratory |
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claim integrity program. |
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Sec. 1224.003. EXEMPTIONS. (a) This chapter does not |
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require registration as a person providing a laboratory claim |
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integrity program by: |
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(1) a health benefit plan issuer; or |
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(2) a utilization review agent that has been issued a |
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certificate of registration under Chapter 4201. |
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(b) The activities of a laboratory claim integrity program |
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are exempt from the requirements of Chapter 4201. |
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Sec. 1224.004. REQUIREMENTS FOR LABORATORY CLAIM INTEGRITY |
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PROGRAMS. (a) A laboratory claim integrity program shall: |
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(1) apply only objective, evidence-based, and |
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population-based clinical laboratory testing reimbursement |
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policies; and |
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(2) include a summary of the program or an electronic |
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link to a summary of the program on its public Internet website. |
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(b) A laboratory claim integrity program may not: |
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(1) require the use of clinical decision support |
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software by an enrollee's physician or health care provider before |
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the physician or provider orders a clinical laboratory test for the |
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enrollee; |
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(2) restrict, limit, or influence a clinical |
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laboratory test provider's choice of electronic health record |
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software, electronic medical record software, or practice |
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management software; |
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(3) restrict, limit, or influence a clinical |
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laboratory test provider's choice of third-party claim-filing |
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service, billing service, or electronic data interchange |
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clearinghouse company; |
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(4) disclose an enrollee's protected health |
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information unless the disclosure is authorized by the enrollee or |
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the enrollee's authorized representative or is permitted without |
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authorization under the Health Insurance Portability and |
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Accountability Act of 1996 (42 U.S.C. Section 1320d et seq.) or |
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under Section 602.053; or |
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(5) hold a delegation from a health benefit plan |
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issuer to make claim determinations. |
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Sec. 1224.005. PROGRAM ACTIONS NOT ADVERSE DETERMINATION. |
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A denial or reduction in payment of a claim that is identified by a |
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laboratory claim integrity program as not meeting the requirements |
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of an applicable health benefit plan clinical laboratory testing |
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reimbursement policy is not an adverse determination for purposes |
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of Chapter 4201. |
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SECTION 2. Chapter 1224, Insurance Code, as added by this |
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Act, applies only to a laboratory claim integrity program contract |
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that is entered into or renewed on or after January 1, 2026. |
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SECTION 3. This Act takes effect September 1, 2025. |