Bill Text: TX HB1621 | 2015-2016 | 84th Legislature | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Relating to utilization review and notice and appeal of certain adverse determinations by utilization review agents.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Passed) 2015-06-19 - Effective on 9/1/15 [HB1621 Detail]
Download: Texas-2015-HB1621-Introduced.html
Bill Title: Relating to utilization review and notice and appeal of certain adverse determinations by utilization review agents.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Passed) 2015-06-19 - Effective on 9/1/15 [HB1621 Detail]
Download: Texas-2015-HB1621-Introduced.html
84R5065 SCL-F | ||
By: Bonnen of Galveston | H.B. No. 1621 |
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relating to notice and appeal of an adverse determination by | ||
utilization review agents. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 4201.304, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 4201.304. TIME FOR NOTICE OF ADVERSE DETERMINATION. | ||
(a) Subject to Subsection (b), a [ |
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provide notice of an adverse determination required by this | ||
subchapter as follows: | ||
(1) with respect to a patient who is hospitalized at | ||
the time of the adverse determination, within one working day by | ||
either telephone or electronic transmission to the provider of | ||
record, followed by a letter within three working days notifying | ||
the patient and the provider of record of the adverse | ||
determination; | ||
(2) with respect to a patient who is not hospitalized | ||
at the time of the adverse determination, within three working days | ||
in writing to the provider of record and the patient; or | ||
(3) within the time appropriate to the circumstances | ||
relating to the delivery of the services to the patient and to the | ||
patient's condition, provided that when denying poststabilization | ||
care subsequent to emergency treatment as requested by a treating | ||
physician or other health care provider, the agent shall provide | ||
the notice to the treating physician or other health care provider | ||
not later than one hour after the time of the request. | ||
(b) A utilization review agent shall provide notice of an | ||
adverse determination for a concurrent review of health care | ||
services not later than the 30th day before the date on which the | ||
health care services will be discontinued. | ||
SECTION 2. Subchapter H, Chapter 4201, Insurance Code, is | ||
amended by adding Section 4201.3555 to read as follows: | ||
Sec. 4201.3555. CONTINUATION OF CONCURRENT HEALTH CARE | ||
SERVICES. The procedures for appealing an adverse determination | ||
for a concurrent review of health care services must provide that: | ||
(1) coverage or benefits for the contested health care | ||
services, including prescription drugs, that are the basis of the | ||
adverse determination continues under the enrollee's health | ||
insurance policy or health benefit plan while the appeal is being | ||
considered; and | ||
(2) without regard to whether the adverse | ||
determination is upheld on appeal, the payor may not charge an | ||
enrollee for the cost of the contested health care services, | ||
including prescription drugs, received during the period the appeal | ||
was considered except for an applicable copayment, coinsurance, or | ||
deductible under the enrollee's health insurance policy or health | ||
benefit plan. | ||
SECTION 3. Subchapter I, Chapter 4201, Insurance Code, is | ||
amended by adding Section 4201.404 to read as follows: | ||
Sec. 4201.404. CONTINUATION OF CONCURRENT HEALTH CARE | ||
SERVICES. The procedures for an independent review of an appeal of | ||
an adverse determination for a concurrent review of health care | ||
services must provide that: | ||
(1) coverage or benefits for the contested health care | ||
services, including prescription drugs, that are the basis of the | ||
adverse determination continues under the enrollee's health | ||
insurance policy or health benefit plan while the review is being | ||
considered; and | ||
(2) without regard to whether the adverse | ||
determination is upheld on review, the payor may not charge an | ||
enrollee for the cost of the contested health care services, | ||
including prescription drugs, received during the period the review | ||
was considered except for an applicable copayment, coinsurance, or | ||
deductible under the enrollee's health insurance policy or health | ||
benefit plan. | ||
SECTION 4. This Act applies only to an adverse | ||
determination made in relation to coverage or benefits under a | ||
health insurance policy or health benefit plan delivered, issued | ||
for delivery, or renewed on or after January 1, 2016. An adverse | ||
determination made in relation to coverage or benefits under a | ||
policy or plan delivered, issued for delivery, or renewed before | ||
January 1, 2016, 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, 2015. |