Bill Text: TX HB2345 | 2017-2018 | 85th Legislature | Introduced


Bill Title: Relating to the performance and appeal of utilization review by and under the direction of physicians.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced) 2017-05-04 - Committee report sent to Calendars [HB2345 Detail]

Download: Texas-2017-HB2345-Introduced.html
  85R7231 SCL-D
 
  By: Workman H.B. No. 2345
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the performance and appeal of utilization review by and
  under the direction of physicians.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 4201.152, Insurance Code, is amended to
  read as follows:
         Sec. 4201.152.  UTILIZATION REVIEW UNDER DIRECTION OF
  PHYSICIAN. A utilization review agent shall conduct utilization
  review under the direction of a physician licensed to practice
  medicine in this [by a] state [licensing agency in the United
  States].
         SECTION 2.  Subchapter D, Chapter 4201, Insurance Code, is
  amended by adding Section 4201.1525 to read as follows:
         Sec. 4201.1525.  UTILIZATION REVIEW BY PHYSICIANS. (a) A
  utilization review agent that uses a physician to conduct
  utilization review may only use a physician licensed to practice
  medicine in this state.
         (b)  A payor that conducts utilization review on the payor's
  own behalf is subject to Subsection (a) as if the payor were a
  utilization review agent.
         SECTION 3.  Section 4201.356, Insurance Code, is amended to
  read as follows:
         Sec. 4201.356.  DECISION BY PHYSICIAN REQUIRED; SPECIALTY
  REVIEW. (a) The procedures for appealing an adverse determination
  must provide that a physician licensed to practice medicine in this
  state makes the decision on the appeal, except as provided by
  Subsection (b).
         (b)  If not later than the 10th working day after the date an
  appeal is denied the enrollee's health care provider states in
  writing good cause for having a particular type of specialty
  provider review the case, a health care provider licensed in this
  state who is of the same or a similar specialty as the health care
  provider who would typically manage the medical or dental
  condition, procedure, or treatment under consideration for review
  shall review the decision denying the appeal. The specialty review
  must be completed within 15 working days of the date the health care
  provider's request for specialty review is received.
         SECTION 4.  Section 4201.357(a), Insurance Code, is amended
  to read as follows:
         (a)  The procedures for appealing an adverse determination
  must include, in addition to the written appeal, a procedure for an
  expedited appeal of a denial of emergency care or a denial of
  continued hospitalization.  That procedure must include a review
  by a health care provider who:
               (1)  has not previously reviewed the case; [and]
               (2)  is of the same or a similar specialty as the health
  care provider who would typically manage the medical or dental
  condition, procedure, or treatment under review in the appeal; and
               (3)  is licensed in this state.
         SECTION 5.  Section 4201.454, Insurance Code, is amended to
  read as follows:
         Sec. 4201.454.  UTILIZATION REVIEW UNDER DIRECTION OF
  PROVIDER OF SAME SPECIALTY. A specialty utilization review agent
  shall conduct utilization review under the direction of a health
  care provider who is of the same specialty as the agent and who is
  licensed or otherwise authorized to provide the specialty health
  care service in this [by a] state [licensing agency in the United
  States].
         SECTION 6.  Section 1305.351(d), Insurance Code, is amended
  to read as follows:
         (d)  A [Notwithstanding Section 4201.152, a] utilization
  review agent or an insurance carrier that uses doctors to perform
  reviews of health care services provided under this chapter,
  including utilization review, or peer reviews under Section
  408.0231(g), Labor Code, may only use doctors licensed to practice
  in this state.
         SECTION 7.  Section 408.023(h), Labor Code, is amended to
  read as follows:
         (h)  A [Notwithstanding Section 4201.152, Insurance Code, a]
  utilization review agent or an insurance carrier that uses doctors
  to perform reviews of health care services provided under this
  subtitle, including utilization review, may only use doctors
  licensed to practice in this state.
         SECTION 8.  The change in law made by this Act applies only
  to utilization review that was requested on or after the effective
  date of this Act. Utilization review that was requested before the
  effective date of this Act 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 9.  This Act takes effect September 1, 2017.
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