Bill Text: TX HB3721 | 2019-2020 | 86th Legislature | Engrossed
Bill Title: Relating to an independent review organization to conduct reviews of certain medical necessity determinations under the Medicaid managed care program.
Spectrum: Slight Partisan Bill (Democrat 2-1)
Status: (Engrossed - Dead) 2019-05-10 - Referred to Health & Human Services [HB3721 Detail]
Download: Texas-2019-HB3721-Engrossed.html
By: Deshotel, Raymond, Zedler | H.B. No. 3721 |
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relating to an independent review organization to conduct reviews | ||
of certain medical necessity determinations under the Medicaid | ||
managed care program. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Section 533.039 to read as follows: | ||
Sec. 533.039. INDEPENDENT REVIEW ORGANIZATIONS. (a) In | ||
this section, "independent review organization" means an | ||
organization certified under Chapter 4202, Insurance Code. | ||
(b) The commission shall contract with an independent | ||
review organization to make review determinations with respect to | ||
disputes at issue in requests for appeal submitted to the | ||
commission challenging a medical necessity determination of a | ||
managed care organization that contracts with the commission under | ||
this chapter, except as provided by Subsection (b-1) or (g). The | ||
executive commissioner by rule shall determine: | ||
(1) the manner in which an independent review | ||
organization is to settle the disputes; | ||
(2) when, subject to Subsection (b-1), in the appeals | ||
process, an organization may be accessed; and | ||
(3) the recourse available after the organization | ||
makes a review determination. | ||
(b-1) With regard to a recipient dispute related to a | ||
reduction in or denial of services on the basis of medical | ||
necessity, the commission shall ensure that an independent review | ||
conducted by an independent review organization under this section | ||
occurs after the managed care organization has conducted an | ||
internal appeal and before the Medicaid fair hearing is granted. A | ||
recipient, or the recipient's parent or legally authorized | ||
representative, described by this subsection may opt out of being | ||
subject to an independent review determination under this section | ||
and instead opt to proceed directly to a Medicaid fair hearing. | ||
(c) The commission shall ensure that a contract entered into | ||
under Subsection (b): | ||
(1) requires an independent review organization to | ||
make a review determination in a timely manner as determined by the | ||
commission; | ||
(2) provides procedures to protect the | ||
confidentiality of medical records transmitted to the organization | ||
for use in conducting an independent review; | ||
(3) sets minimum qualifications for and requires the | ||
independence of each physician or other health care provider making | ||
a review determination on behalf of the organization; | ||
(4) subject to Subsection (c-1), specifies the | ||
procedures to be used by the organization in making review | ||
determinations; | ||
(5) requires the timely notice to a recipient of the | ||
results of an independent review, including the clinical basis for | ||
the review determination; | ||
(6) requires that the organization report the | ||
following aggregate information to the commission in the form and | ||
manner and at the times prescribed by the commission: | ||
(A) the number of requests for independent | ||
reviews received by the independent review organization; | ||
(B) the number of independent reviews conducted; | ||
(C) the number of review determinations made: | ||
(i) in favor of a managed care | ||
organization; and | ||
(ii) in favor of a recipient; | ||
(D) the number of review determinations that | ||
resulted in a managed care organization deciding to cover the | ||
service at issue; | ||
(E) a summary of the disputes at issue in | ||
independent reviews; | ||
(F) a summary of the services that were the | ||
subject of independent reviews; and | ||
(G) the average time the organization took to | ||
complete an independent review and make a review determination; and | ||
(7) requires that, in addition to the aggregate | ||
information required by Subdivision (6), the organization include | ||
in the report the information required by that subdivision | ||
categorized by managed care organization. | ||
(c-1) The commission shall establish a common procedure for | ||
independent reviews conducted under this section. The procedure | ||
must provide that a service ordered by a health care provider is | ||
presumed medically necessary and the managed care organization | ||
bears the burden of proof to show the service is not medically | ||
necessary. Medical necessity must be based on publicly available, | ||
up-to-date, evidence-based, and peer-reviewed clinical criteria. | ||
The commission shall also establish a procedure for expedited | ||
reviews that allows the reviewer to identify an appeal that | ||
requires an expedited resolution. | ||
(d) An independent review organization with which the | ||
commission contracts under this section shall: | ||
(1) obtain all information relating to the dispute at | ||
issue from the managed care organization and the provider in | ||
accordance with time frames prescribed by the commission; | ||
(2) assign a physician or other health care provider | ||
with appropriate expertise as a reviewer to make a review | ||
determination; | ||
(3) for each review, perform a check to ensure that the | ||
organization and the physician or other health care provider | ||
assigned to make a review determination do not have a conflict of | ||
interest, as defined in the contract entered into between the | ||
commission and the organization; | ||
(4) communicate procedural rules, approved by the | ||
commission, and other information regarding the appeals process to | ||
all parties; and | ||
(5) render a timely review determination, as | ||
determined by the commission. | ||
(e) The commission shall ensure that the managed care | ||
organization, the provider, and the recipient involved in a dispute | ||
do not have a choice in the reviewer who is assigned to perform the | ||
review. | ||
(e-1) An independent review organization's review | ||
determination of medical necessity establishes the minimum level of | ||
services a recipient must receive. | ||
(f) A managed care organization described by Subsection (b) | ||
may not have a financial relationship with or ownership interest in | ||
an independent review organization with which the commission | ||
contracts. In selecting an independent review organization with | ||
which to contract, the commission shall avoid conflicts of interest | ||
by considering and monitoring existing relationships between | ||
independent review organizations and managed care organizations. | ||
An independent review organization with which the commission | ||
contracts must: | ||
(1) be overseen by a medical director who is a | ||
physician licensed in this state; and | ||
(2) employ or be able to consult with staff with | ||
experience in providing private duty nursing services and long-term | ||
services and supports. | ||
(g) This section does not apply to, and an independent | ||
review organization may not make a review determination with | ||
respect to, a dispute involving the commission's office of | ||
inspector general or an action taken at the direction of that | ||
office, including a dispute relating to: | ||
(1) an action taken by a managed care organization at | ||
the direction of the office under the lock-in program established | ||
in accordance with 42 C.F.R. Part 431.54(e); or | ||
(2) the termination or potential termination of a | ||
provider's enrollment in a managed care organization's provider | ||
network at the direction of the office. | ||
(h) The executive commissioner shall adopt rules necessary | ||
to implement this section. | ||
SECTION 2. If before implementing any provision of this Act | ||
a state agency determines that a waiver or authorization from a | ||
federal agency is necessary for implementation of that provision, | ||
the agency affected by the provision shall request the waiver or | ||
authorization and may delay implementing that provision until the | ||
waiver or authorization is granted. | ||
SECTION 3. This Act takes effect September 1, 2019. |