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A BILL TO BE ENTITLED
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AN ACT
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relating to notice from a health benefit plan issuer to the Texas |
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Department of Insurance regarding a physician's or health care |
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provider's preauthorization exemption status. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter N, Chapter 4201, Insurance Code, is |
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amended by adding Section 4201.660 to read as follows: |
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Sec. 4201.660. EXEMPTION STATUS NOTIFICATION TO |
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DEPARTMENT; DATABASE AND REPORT. (a) A health maintenance |
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organization or insurer that uses a preauthorization process for |
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health care services shall provide written notice to the department |
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of a physician's or provider's preauthorization exemption status |
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under this subchapter not later than the 10th day after the date on |
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which the health maintenance organization or insurer: |
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(1) completes an evaluation of the physician or |
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provider as required by Section 4201.653(b) and determines whether |
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the physician or provider qualifies for an exemption; |
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(2) determines that the health maintenance |
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organization or insurer will continue the physician's or provider's |
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exemption under Section 4201.653(c); |
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(3) provides notice to the physician or provider of a |
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determination to rescind the physician's or provider's exemption; |
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or |
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(4) makes an internal appeal determination or receives |
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a determination from an independent review organization under |
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Section 4201.656 affirming or denying the health maintenance |
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organization's or insurer's determination to rescind the |
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physician's or provider's exemption. |
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(b) The department shall establish and maintain a database |
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of preauthorization exemption grants, denials, recissions, and |
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internal appeal and independent review determinations. On the |
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request of a physician or provider, the department shall provide |
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the physician or provider with information regarding the |
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physician's or provider's preauthorization exemption status with |
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respect to each relevant health maintenance organization or insurer |
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and with respect to each relevant health care service. |
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(c) The department shall collect and compile data |
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regarding: |
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(1) the number and timing of evaluations being |
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conducted by each health maintenance organization or insurer under |
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this subchapter; |
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(2) the number of internal appeals or independent |
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reviews conducted by or with respect to each health maintenance |
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organization or insurer under this subchapter; |
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(3) the number of exemptions granted, denied, or |
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rescinded by each health maintenance organization or insurer, by |
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provider type and health care service; and |
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(4) the number and outcomes of internal appeals or |
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independent reviews conducted by or with respect to each health |
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maintenance organization or insurer. |
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(d) The department shall annually prepare a statistical |
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report reflecting the data collected under Subsection (c) and make |
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the report available to the public on request. |
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SECTION 2. Section 4201.660, Insurance Code, as added by |
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this Act, applies only to a determination regarding a physician's |
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or provider's preauthorization exemption status made on or after |
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the effective date of this Act. |
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SECTION 3. This Act takes effect September 1, 2025. |