Bill Text: TX HB3812 | 2025-2026 | 89th Legislature | Enrolled

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Bill Title: Relating to health benefit plan preauthorization requirements for certain health care services and the direction of utilization review by physicians.

Sponsorship: Slight Partisan Bill (Republican 8-3)

Status: (Passed) 2025-06-20 - Effective on 9/1/25 [HB3812 Detail]

Download: Texas-2025-HB3812-Enrolled.html

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H.B. No. 3812

AN ACT
relating to health benefit plan preauthorization requirements for
certain health care services and the direction of utilization
review by 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 state. The physician may not hold a license to
practice administrative medicine under Section 155.009,
Occupations Code.
SECTION 2. Section 4201.651(a), Insurance Code, is amended
to read as follows:
(a) In this subchapter:
(1) "Affiliate" has the meaning assigned by Section
823.003.
(2) "Preauthorization"[, "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.
SECTION 3. Section 4201.653, Insurance Code, is amended by
amending Subsections (a) and (b) and adding Subsection (a-1) to
read as follows:
(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 one-year
[six-month] evaluation period, as described by Subsection (b):
(1) [,] the health maintenance organization or
insurer, including any affiliate, 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; and
(2) the physician or provider has provided the
particular health care service at least five times during the
evaluation period.
(a-1) In conducting an evaluation for an exemption under
this section, a health maintenance organization or insurer must
include all preauthorization requests submitted by a physician or
provider to the health maintenance organization or insurer, or its
affiliate, considering all health insurance policies and health
benefit plans issued or administered by the health maintenance
organization or insurer, or its affiliate, regardless of whether
the preauthorization request was made in connection with a health
insurance policy or health benefit plan that is subject to this
subchapter.
(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 year
[six months].
SECTION 4. Section 4201.655, Insurance Code, is amended by
amending Subsections (a) and (b) and adding Subsection (b-1) to
read as follows:
(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 a [each] year
beginning on or after the first anniversary of the last day of the
most recent evaluation period for the exemption;
(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. The reviewing physician may not hold a
license to practice administrative medicine under Section 155.009,
Occupations Code.
(b-1) Notwithstanding Subsection (a)(2), if there are fewer
than five claims submitted by the physician or provider during the
most recent evaluation period described by Section 4201.653(b) for
a particular health care service, the health maintenance
organization or insurer shall review all the claims submitted by
the physician or provider during the most recent evaluation period
for that service.
SECTION 5. Section 4201.656(a), Insurance Code, is amended
to read as follows:
(a) A physician or provider has a right to a review of an
adverse determination regarding a preauthorization exemption,
including a health maintenance organization's or insurer's
determination to deny an exemption to the physician or provider
under Section 4201.653, to 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.
SECTION 6. Section 4201.658, Insurance Code, is amended to
read as follows:
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 one-year
[six-month] evaluation period that follows the evaluation period
which formed the basis of the rescission or denial of an exemption.
SECTION 7. Sections 4201.659(b) and (c), Insurance Code,
are amended to read as follows:
(b) Regardless of whether an exemption is rescinded after
the provision of a health care service subject to the exemption, a
[A] health maintenance organization or an insurer may not conduct a
utilization [retrospective] review or require another review
similar to preauthorization of the [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 utilization [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).
SECTION 8. Subchapter N, Chapter 4201, Insurance Code, is
amended by adding Section 4201.660 to read as follows:
Sec. 4201.660. REPORT. (a) Each health maintenance
organization and insurer shall submit to the department, in the
form and manner prescribed by the commissioner, an annual written
report, for each health care service subject to an exemption under
Section 4201.653, on the:
(1) exemptions granted by the health maintenance
organization or insurer for the service;
(2) determinations by the health maintenance
organization or insurer to rescind or deny an exemption for the
service, including the number of exemptions denied or rescinded by
the health maintenance organization or insurer under Section
4201.655; and
(3) independent reviews of determinations conducted
by an independent review organization under Section 4201.656,
including:
(A) the number of determinations made by the
health maintenance organization or insurer for which a physician or
provider requested an independent review under Section 4201.656;
and
(B) the outcome of each independent review
described by Paragraph (A).
(b) Subject to this subsection, a report submitted under
Subsection (a) is public information subject to disclosure under
Chapter 552, Government Code. The department shall ensure that the
report does not contain any identifying information before
disclosing the report in accordance with Chapter 552, Government
Code.
SECTION 9. (a) The change in law made by this Act applies
only to utilization review conducted on or after the effective date
of this Act. Utilization review conducted 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.
(b) A preauthorization exemption provided under Section
4201.653, Insurance Code, before the effective date of this Act may
not be rescinded before the first anniversary of the last day of the
most recent evaluation period for the exemption.
SECTION 10. This Act takes effect September 1, 2025.
______________________________ ______________________________
President of the Senate Speaker of the House
I certify that H.B. No. 3812 was passed by the House on May
15, 2025, by the following vote: Yeas 116, Nays 23, 3 present, not
voting.
______________________________
Chief Clerk of the House
I certify that H.B. No. 3812 was passed by the Senate on May
27, 2025, by the following vote: Yeas 30, Nays 1.
______________________________
Secretary of the Senate
APPROVED: _____________________
Date
_____________________
Governor