86R8049 KFF-D
 
  By: Deshotel H.B. No. 3721
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  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
  complaints or disputes, including a dispute at issue in a request
  for appeal, submitted to the commission challenging a medical
  necessity determination of a managed care organization that
  contracts with the commission under this chapter. The executive
  commissioner by rule shall determine:
               (1)  the manner in which an independent review
  organization is to settle complaints or disputes;
               (2)  when, in the appeals process, an organization may
  be accessed; and
               (3)  the recourse available after the organization
  makes a review determination.
         (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;
               (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)  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 complaints or 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.
         (d)  An independent review organization with which the
  commission contracts under this section shall:
               (1)  obtain all information relating to the complaint
  or 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
  complaint or dispute do not have a choice in the reviewer who is
  assigned to perform the review.
         (f)  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.
         (g)  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.