Bill Text: TX HB3459 | 2021-2022 | 87th Legislature | Enrolled
Bill Title: Relating to preauthorization requirements for certain health care services and utilization review for certain health benefit plans.
Spectrum: Slight Partisan Bill (Republican 2-1)
Status: (Passed) 2021-06-18 - Effective on 9/1/21 [HB3459 Detail]
Download: Texas-2021-HB3459-Enrolled.html
H.B. No. 3459 |
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relating to preauthorization requirements for certain health care | ||
services and utilization review for certain health benefit plans. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subchapter E, Chapter 1551, Insurance Code, is | ||
amended by adding Section 1551.2181 to read as follows: | ||
Sec. 1551.2181. EXEMPTION FROM PREAUTHORIZATION | ||
REQUIREMENTS FOR PHYSICIANS AND HEALTH CARE PROVIDERS PROVIDING | ||
CERTAIN HEALTH CARE SERVICES. A preauthorization process used by a | ||
health benefit plan provided under this chapter is subject to the | ||
same limitations and requirements provided by Subchapter N, Chapter | ||
4201, for a preauthorization process used by an insurer. | ||
SECTION 2. Subchapter D, Chapter 1575, Insurance Code, is | ||
amended by adding Section 1575.1701 to read as follows: | ||
Sec. 1575.1701. EXEMPTION FROM PREAUTHORIZATION | ||
REQUIREMENTS FOR PHYSICIANS AND HEALTH CARE PROVIDERS PROVIDING | ||
CERTAIN HEALTH CARE SERVICES. A preauthorization process used by a | ||
health benefit plan provided under this chapter is subject to the | ||
same limitations and requirements provided by Subchapter N, Chapter | ||
4201, for a preauthorization process used by an insurer. | ||
SECTION 3. Subchapter C, Chapter 1579, Insurance Code, is | ||
amended by adding Section 1579.1061 to read as follows: | ||
Sec. 1579.1061. EXEMPTION FROM PREAUTHORIZATION | ||
REQUIREMENTS FOR PHYSICIANS AND HEALTH CARE PROVIDERS PROVIDING | ||
CERTAIN HEALTH CARE SERVICES. A preauthorization process used by a | ||
health coverage plan provided under this chapter is subject to the | ||
same limitations and requirements provided by Subchapter N, Chapter | ||
4201, for a preauthorization process used by an insurer. | ||
SECTION 4. Section 4201.206, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE | ||
ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the | ||
notice requirements of Subchapter G, before an adverse | ||
determination is issued by a utilization review agent who questions | ||
the medical necessity, the appropriateness, or the experimental or | ||
investigational nature of a health care service, the agent shall | ||
provide the health care provider who ordered, requested, provided, | ||
or is to provide the service a reasonable opportunity to discuss | ||
with a physician licensed to practice medicine in this state the | ||
patient's treatment plan and the clinical basis for the agent's | ||
determination. | ||
(b) If the health care service described by Subsection (a) | ||
was ordered, requested, or provided, or is to be provided by a | ||
physician, the opportunity described by that subsection must be | ||
with a physician licensed to practice medicine in this state and who | ||
has the same or similar specialty as the physician. | ||
SECTION 5. Chapter 4201, Insurance Code, is amended by | ||
adding Subchapter N to read as follows: | ||
SUBCHAPTER N. EXEMPTION FROM PREAUTHORIZATION REQUIREMENTS FOR | ||
PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH CARE SERVICES | ||
Sec. 4201.651. DEFINITIONS. (a) In this subchapter, | ||
"preauthorization" means a determination by a health maintenance | ||
organization, insurer, or person contracting with a health | ||
maintenance organization or insurer that health care services | ||
proposed to be provided to a patient are medically necessary and | ||
appropriate. | ||
(b) In this subchapter, terms defined by Section 843.002, | ||
including "health care services," "physician," and "provider," | ||
have the meanings assigned by that section. | ||
Sec. 4201.652. APPLICABILITY OF SUBCHAPTER. This | ||
subchapter applies only to: | ||
(1) a health benefit plan offered by a health | ||
maintenance organization operating under Chapter 843, except that | ||
this subchapter does not apply to: | ||
(A) the child health plan program under Chapter | ||
62, Health and Safety Code, or the health benefits plan for children | ||
under Chapter 63, Health and Safety Code; or | ||
(B) the state Medicaid program, including the | ||
Medicaid managed care program operated under Chapter 533, | ||
Government Code; | ||
(2) a preferred provider benefit plan or exclusive | ||
provider benefit plan offered by an insurer under Chapter 1301; and | ||
(3) a person who contracts with a health maintenance | ||
organization or insurer to issue preauthorization determinations | ||
or perform the functions described in this subchapter for a health | ||
benefit plan to which this subchapter applies. | ||
Sec. 4201.653. EXEMPTION FROM PREAUTHORIZATION | ||
REQUIREMENTS FOR PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH | ||
CARE SERVICES. (a) A health maintenance organization or an insurer | ||
that uses a preauthorization process for health care services may | ||
not require a physician or provider to obtain preauthorization for | ||
a particular health care service if, in the most recent six-month | ||
evaluation period, as described by Subsection (b), the health | ||
maintenance organization or insurer has approved or would have | ||
approved not less than 90 percent of the preauthorization requests | ||
submitted by the physician or provider for the particular health | ||
care service. | ||
(b) Except as provided by Subsection (c), a health | ||
maintenance organization or insurer shall evaluate whether a | ||
physician or provider qualifies for an exemption from | ||
preauthorization requirements under Subsection (a) once every six | ||
months. | ||
(c) A health maintenance organization or insurer may | ||
continue an exemption under Subsection (a) without evaluating | ||
whether the physician or provider qualifies for the exemption under | ||
Subsection (a) for a particular evaluation period. | ||
(d) A physician or provider is not required to request an | ||
exemption under Subsection (a) to qualify for the exemption. | ||
Sec. 4201.654. DURATION OF PREAUTHORIZATION EXEMPTION. (a) | ||
A physician's or provider's exemption from preauthorization | ||
requirements under Section 4201.653 remains in effect until: | ||
(1) the 30th day after the date the health maintenance | ||
organization or insurer notifies the physician or provider of the | ||
health maintenance organization's or insurer's determination to | ||
rescind the exemption under Section 4201.655, if the physician or | ||
provider does not appeal the health maintenance organization's or | ||
insurer's determination; or | ||
(2) if the physician or provider appeals the | ||
determination, the fifth day after the date the independent review | ||
organization affirms the health maintenance organization's or | ||
insurer's determination to rescind the exemption. | ||
(b) If a health maintenance organization or insurer does not | ||
finalize a rescission determination as specified in Subsection (a), | ||
then the physician or provider is considered to have met the | ||
criteria under Section 4201.653 to continue to qualify for the | ||
exemption. | ||
Sec. 4201.655. DENIAL OR RESCISSION OF PREAUTHORIZATION | ||
EXEMPTION. (a) A health maintenance organization or insurer may | ||
rescind an exemption from preauthorization requirements under | ||
Section 4201.653 only: | ||
(1) during January or June of each year; | ||
(2) if the health maintenance organization or insurer | ||
makes a determination, on the basis of a retrospective review of a | ||
random sample of not fewer than five and no more than 20 claims | ||
submitted by the physician or provider during the most recent | ||
evaluation period described by Section 4201.653(b), that less than | ||
90 percent of the claims for the particular health care service met | ||
the medical necessity criteria that would have been used by the | ||
health maintenance organization or insurer when conducting | ||
preauthorization review for the particular health care service | ||
during the relevant evaluation period; and | ||
(3) if the health maintenance organization or insurer | ||
complies with other applicable requirements specified in this | ||
section, including: | ||
(A) notifying the physician or provider not less | ||
than 25 days before the proposed rescission is to take effect; and | ||
(B) providing with the notice under Paragraph | ||
(A): | ||
(i) the sample information used to make the | ||
determination under Subdivision (2); and | ||
(ii) a plain language explanation of how | ||
the physician or provider may appeal and seek an independent review | ||
of the determination. | ||
(b) A determination made under Subsection (a)(2) must be | ||
made by an individual licensed to practice medicine in this state. | ||
For a determination made under Subsection (a)(2) with respect to a | ||
physician, the determination must be made by an individual licensed | ||
to practice medicine in this state who has the same or similar | ||
specialty as that physician. | ||
(c) A health maintenance organization or insurer may deny an | ||
exemption from preauthorization requirements under Section | ||
4201.653 only if: | ||
(1) the physician or provider does not have the | ||
exemption at the time of the relevant evaluation period; and | ||
(2) the health maintenance organization or insurer | ||
provides the physician or provider with actual statistics and data | ||
for the relevant preauthorization request evaluation period and | ||
detailed information sufficient to demonstrate that the physician | ||
or provider does not meet the criteria for an exemption from | ||
preauthorization requirements for the particular health care | ||
service under Section 4201.653. | ||
Sec. 4201.656. INDEPENDENT REVIEW OF EXEMPTION | ||
DETERMINATION. (a) A physician or provider has a right to a review | ||
of an adverse determination regarding a preauthorization exemption | ||
be conducted by an independent review organization. A health | ||
maintenance organization or insurer may not require a physician or | ||
provider to engage in an internal appeal process before requesting | ||
a review by an independent review organization under this section. | ||
(b) A health maintenance organization or insurer shall pay: | ||
(1) for any appeal or independent review of an adverse | ||
determination regarding a preauthorization exemption requested | ||
under this section; and | ||
(2) a reasonable fee determined by the Texas Medical | ||
Board for any copies of medical records or other documents | ||
requested from a physician or provider during an exemption | ||
rescission review requested under this section. | ||
(c) An independent review organization must complete an | ||
expedited review of an adverse determination regarding a | ||
preauthorization exemption not later than the 30th day after the | ||
date a physician or provider files the request for a review under | ||
this section. | ||
(d) A physician or provider may request that the independent | ||
review organization consider another random sample of not less than | ||
five and no more than 20 claims submitted to the health maintenance | ||
organization or insurer by the physician or provider during the | ||
relevant evaluation period for the relevant health care service as | ||
part of its review. If the physician or provider makes a request | ||
under this subsection, the independent review organization shall | ||
base its determination on the medical necessity of claims reviewed | ||
by the health maintenance organization or insurer under Section | ||
4201.655 and reviewed under this subsection. | ||
Sec. 4201.657. EFFECT OF APPEAL OR INDEPENDENT REVIEW | ||
DETERMINATION. (a) A health maintenance organization or insurer | ||
is bound by an appeal or independent review determination that does | ||
not affirm the determination made by the health maintenance | ||
organization or insurer to rescind a preauthorization exemption. | ||
(b) A health maintenance organization or insurer may not | ||
retroactively deny a health care service on the basis of a | ||
rescission of an exemption, even if the health maintenance | ||
organization's or insurer's determination to rescind the | ||
preauthorization exemption is affirmed by an independent review | ||
organization. | ||
(c) If a determination of a preauthorization exemption made | ||
by the health maintenance organization or insurer is overturned on | ||
review by an independent review organization, the health | ||
maintenance organization or insurer: | ||
(1) may not attempt to rescind the exemption before | ||
the end of the next evaluation period that occurs; and | ||
(2) may only rescind the exemption after if the health | ||
maintenance organization or insurer complies with Sections | ||
4201.655 and 4201.656. | ||
Sec. 4201.658. ELIGIBILITY FOR PREAUTHORIZATION EXEMPTION | ||
FOLLOWING FINALIZED EXEMPTION RESCISSION OR DENIAL. After a final | ||
determination or review affirming the rescission or denial of an | ||
exemption for a specific health care service under Section | ||
4201.653, a physician or provider is eligible for consideration of | ||
an exemption for the same health care service after the six-month | ||
evaluation period that follows the evaluation period which formed | ||
the basis of the rescission or denial of an exemption. | ||
Sec. 4201.659. EFFECT OF PREAUTHORIZATION EXEMPTION. (a) | ||
A health maintenance organization or insurer may not deny or reduce | ||
payment to a physician or provider for a health care service for | ||
which the physician or provider has qualified for an exemption from | ||
preauthorization requirements under Section 4201.653 based on | ||
medical necessity or appropriateness of care unless the physician | ||
or provider: | ||
(1) knowingly and materially misrepresented the | ||
health care service in a request for payment submitted to the health | ||
maintenance organization or insurer with the specific intent to | ||
deceive and obtain an unlawful payment from the health maintenance | ||
organization or insurer; or | ||
(2) failed to substantially perform the health care | ||
service. | ||
(b) A health maintenance organization or an insurer may not | ||
conduct a retrospective review of a health care service subject to | ||
an exemption except: | ||
(1) to determine if the physician or provider still | ||
qualifies for an exemption under this subchapter; or | ||
(2) if the health maintenance organization or insurer | ||
has a reasonable cause to suspect a basis for denial exists under | ||
Subsection (a). | ||
(c) For a retrospective review described by Subsection | ||
(b)(2), nothing in this subchapter may be construed to modify or | ||
otherwise affect: | ||
(1) the requirements under or application of Section | ||
4201.305, including any timeframes specified by that section; or | ||
(2) any other applicable law, except to prescribe the | ||
only circumstances under which: | ||
(A) a retrospective utilization review may occur | ||
as specified by Subsection (b)(2); or | ||
(B) payment may be denied or reduced as specified | ||
by Subsection (a). | ||
(d) Not later than five days after qualifying for an | ||
exemption from preauthorization requirements under Section | ||
4201.653, a health maintenance organization or insurer must provide | ||
to a physician or provider a notice that includes: | ||
(1) a statement that the physician or provider | ||
qualifies for an exemption from preauthorization requirements | ||
under Section 4201.653; | ||
(2) a list of the health care services and health | ||
benefit plans to which the exemption applies; and | ||
(3) a statement of the duration of the exemption. | ||
(e) If a physician or provider submits a preauthorization | ||
request for a health care service for which the physician or | ||
provider qualifies for an exemption from preauthorization | ||
requirements under Section 4201.653, the health maintenance | ||
organization or insurer must promptly provide a notice to the | ||
physician or provider that includes: | ||
(1) the information described by Subsection (d); and | ||
(2) a notification of the health maintenance | ||
organization's or insurer's payment requirements. | ||
(f) Nothing in this subchapter may be construed to: | ||
(1) authorize a physician or provider to provide a | ||
health care service outside the scope of the provider's applicable | ||
license issued under Title 3, Occupations Code; or | ||
(2) require a health maintenance organization or | ||
insurer to pay for a health care service described by Subdivision | ||
(1) that is performed in violation of the laws of this state. | ||
SECTION 6. Subchapter N, Chapter 4201, Insurance Code, as | ||
added by this Act, applies only to a request for preauthorization of | ||
health care services made on or after January 1, 2022. A request for | ||
preauthorization of health care services made before January 1, | ||
2022, 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 7. Section 4201.206, Insurance Code, as amended by | ||
this Act, applies only to a utilization review requested on or after | ||
the effective date of this Act. A utilization review 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 8. This Act takes effect September 1, 2021. | ||
______________________________ | ______________________________ | |
President of the Senate | Speaker of the House | |
I certify that H.B. No. 3459 was passed by the House on May 7, | ||
2021, by the following vote: Yeas 127, Nays 16, 1 present, not | ||
voting; that the House concurred in Senate amendments to H.B. No. | ||
3459 on May 28, 2021, by the following vote: Yeas 140, Nays 4, 2 | ||
present, not voting; and that the House adopted H.C.R. No. 112 | ||
authorizing certain corrections in H.B. No. 3459 on May 29, 2021, by | ||
the following vote: Yeas 139, Nays 1, 1 present, not voting. | ||
______________________________ | ||
Chief Clerk of the House | ||
I certify that H.B. No. 3459 was passed by the Senate, with | ||
amendments, on May 22, 2021, by the following vote: Yeas 29, Nays | ||
1; and that the Senate adopted H.C.R. No. 112 authorizing certain | ||
corrections in H.B. No. 3459 on May 30, 2021, by the following vote: | ||
Yeas 31, Nays 0. | ||
______________________________ | ||
Secretary of the Senate | ||
APPROVED: __________________ | ||
Date | ||
__________________ | ||
Governor |