Bill Text: TX HB5113 | 2023-2024 | 88th Legislature | Introduced

---

Bill Title: Relating to utilization review requirements for a health care service provided by a network physician or provider.

Sponsorship: Partisan Bill (Democrat 1)

Status: (Introduced - Dead) 2023-03-24 - Referred to Insurance [HB5113 Detail]

Download: Texas-2023-HB5113-Introduced.html

---

88R759 SCL-D
By: Johnson of Dallas H.B. No. 5113

A BILL TO BE ENTITLED
AN ACT
relating to utilization review requirements for a health care
service provided by a network physician or provider.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter J, Chapter 843, Insurance Code, is
amended by adding Section 843.355 to read as follows:
Sec. 843.355. UTILIZATION REVIEW FOR PARTICIPATING
PHYSICIAN OR PROVIDER PROHIBITED. A health maintenance
organization may not require utilization review, including a
preauthorization determination that a health care service is
medically necessary and appropriate, of a health care service
provided to an enrollee by a participating physician or provider.
SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code, is
amended by adding Section 1301.1345 to read as follows:
Sec. 1301.1345. UTILIZATION REVIEW FOR PREFERRED PHYSICIAN
OR PROVIDER PROHIBITED. (a) In this section, "utilization review"
has the meaning assigned by Section 4201.002.
(b) An insurer may not require utilization review,
including preauthorization, of a medical care or health care
service provided to an insured by a preferred physician or
provider.
SECTION 3. The heading to Section 1301.135, Insurance Code,
is amended to read as follows:
Sec. 1301.135. PREAUTHORIZATION OF MEDICAL AND HEALTH CARE
SERVICES FOR NONPREFERRED PHYSICIAN OR PROVIDER.
SECTION 4. Sections 1301.135(d) and (f), Insurance Code,
are amended to read as follows:
(d) If [the] proposed medical care or health care services
involve inpatient care and the insurer requires preauthorization as
a condition of payment of a nonpreferred provider, the insurer
shall review the request and issue a length of stay for the
admission into a health care facility based on the recommendation
of the patient's nonpreferred [physician or health care] provider
and the insurer's written medically accepted screening criteria and
review procedures. If the proposed medical or health care services
are to be provided to a patient who is an inpatient in a health care
facility at the time the services are proposed, the insurer shall
review the request and issue a determination indicating whether
proposed services are preauthorized within 24 hours of the request
by the nonpreferred physician or provider.
(f) If an insurer has preauthorized medical care or health
care services, the insurer may not deny or reduce payment to the
nonpreferred physician or health care provider for those services
based on medical necessity or appropriateness of care unless the
nonpreferred physician or provider has materially misrepresented
the proposed medical or health care services or has substantially
failed to perform the proposed medical or health care services.
SECTION 5. Section 1301.1351(d), Insurance Code, is amended
to read as follows:
(d) If a requirement or information described by Subsection
(a) is licensed, proprietary, or copyrighted material that the
insurer has received from a third party with which the insurer has
contracted, to comply with a posting requirement described by
Subsection (b), the insurer may, instead of making that information
publicly available on the insurer's Internet website, provide the
material to a nonpreferred [physician or health care] provider who
submits a preauthorization request using a nonpublic secured
Internet website link or other protected, nonpublic electronic
means.
SECTION 6. The following provisions of the Insurance Code
are repealed:
(1) Section 843.348;
(2) Section 843.3481;
(3) Section 843.3482;
(4) Section 843.3483; and
(5) Sections 1301.135(a), (b), and (c).
SECTION 7. The changes in law made by this Act apply only to
a health benefit plan delivered, issued for delivery, or renewed on
or after January 1, 2024. A health benefit plan delivered, issued
for delivery, or renewed before January 1, 2024, 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, 2023.