Texas 2009 - 81st Regular

Texas House Bill HB2250 Compare Versions

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1	1	81R8579 PB-F
2	2	By: Hunter, Gonzalez Toureilles, Fletcher H.B. No. 2250
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to payment of claims to pharmacies and pharmacists.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	SECTION 1. Section 843.002, Insurance Code, is amended by
10	10	adding Subdivision (9-a) to read as follows:
11	11	(9-a) "Extrapolation" means a mathematical process or
12	12	technique used by a health maintenance organization or pharmacy
13	13	benefit manager that administers pharmacy claims for a health
14	14	maintenance organization in the audit of a pharmacy or pharmacist
15	15	to estimate audit results or findings for a larger batch or group of
16	16	claims not reviewed by the health maintenance organization or
17	17	pharmacy benefit manager.
18	18	SECTION 2. Section 843.338, Insurance Code, is amended to
19	19	read as follows:
20	20	Sec. 843.338. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except
21	21	as provided by Sections [Section] 843.3385 and 843.339, not later
22	22	than the 45th day after the date on which a health maintenance
23	23	organization receives a clean claim from a participating physician
24	24	or provider in a nonelectronic format or the 30th day after the date
25	25	the health maintenance organization receives a clean claim from a
26	26	participating physician or provider that is electronically
27	27	submitted, the health maintenance organization shall make a
28	28	determination of whether the claim is payable and:
29	29	(1) if the health maintenance organization determines
30	30	the entire claim is payable, pay the total amount of the claim in
31	31	accordance with the contract between the physician or provider and
32	32	the health maintenance organization;
33	33	(2) if the health maintenance organization determines
34	34	a portion of the claim is payable, pay the portion of the claim that
35	35	is not in dispute and notify the physician or provider in writing
36	36	why the remaining portion of the claim will not be paid; or
37	37	(3) if the health maintenance organization determines
38	38	that the claim is not payable, notify the physician or provider in
39	39	writing why the claim will not be paid.
40	40	SECTION 3. Section 843.339, Insurance Code, is amended to
41	41	read as follows:
42	42	Sec. 843.339. DEADLINE FOR ACTION ON [CERTAIN] PRESCRIPTION
43	43	CLAIMS; PAYMENT. (a) A [Not later than the 21st day after the date
44	44	a] health maintenance organization, or a pharmacy benefit manager
45	45	that administers pharmacy claims for the health maintenance
46	46	organization, that affirmatively adjudicates a pharmacy claim that
47	47	is electronically submitted, [the health maintenance organization]
48	48	shall pay the total amount of the claim through electronic funds
49	49	transfer not later than the 14th day after the date on which the
50	50	claim was affirmatively adjudicated.
51	51	(b) A health maintenance organization, or a pharmacy
52	52	benefit manager that administers pharmacy claims for the health
53	53	maintenance organization, that affirmatively adjudicates a
54	54	pharmacy claim that is not electronically submitted, shall pay the
55	55	total amount of the claim not later than the 21st day after the date
56	56	on which the claim was affirmatively adjudicated.
57	57	SECTION 4. Section 843.340, Insurance Code, is amended by
58	58	adding Subsections (f) and (g) to read as follows:
59	59	(f) A health maintenance organization or a pharmacy benefit
60	60	manager that administers pharmacy claims for the health maintenance
61	61	organization may not use extrapolation to complete the audit of a
62	62	provider who is a pharmacist or pharmacy. A health maintenance
63	63	organization or a pharmacy benefit manager that administers
64	64	pharmacy claims for the health maintenance organization may not
65	65	require extrapolation audits as a condition of participation in the
66	66	health maintenance organization's contract, network, or program
67	67	for a provider who is a pharmacist or pharmacy.
68	68	(g) A health maintenance organization or a pharmacy benefit
69	69	manager that administers pharmacy claims for the health maintenance
70	70	organization that performs an on-site audit under this chapter of a
71	71	provider who is a pharmacist or pharmacy shall provide the provider
72	72	reasonable notice of the audit and accommodate the provider's
73	73	schedule to the greatest extent possible. The notice required
74	74	under this subsection must be in writing and must be sent by
75	75	certified mail to the provider not later than the 15th day before
76	76	the date on which the on-site audit is scheduled to occur.
77	77	SECTION 5. Section 843.344, Insurance Code, is amended to
78	78	read as follows:
79	79	Sec. 843.344. APPLICABILITY OF SUBCHAPTER TO ENTITIES
80	80	CONTRACTING WITH HEALTH MAINTENANCE ORGANIZATION. This subchapter
81	81	applies to a person, including a pharmacy benefit manager, with
82	82	whom a health maintenance organization contracts to:
83	83	(1) process or pay claims;
84	84	(2) obtain the services of physicians and providers to
85	85	provide health care services to enrollees; or
86	86	(3) issue verifications or preauthorizations.
87	87	SECTION 6. Subchapter J, Chapter 843, Insurance Code, is
88	88	amended by adding Sections 843.354, 843.355, and 843.356 to read as
89	89	follows:
90	90	Sec. 843.354. DEPARTMENT ENFORCEMENT OF PHARMACY CLAIMS.
91	91	(a) Notwithstanding any other provision of this subchapter, a
92	92	dispute regarding payment of a claim to a provider who is a
93	93	pharmacist or pharmacy shall be resolved as provided by this
94	94	section.
95	95	(b) A provider who is a pharmacist or pharmacy may submit a
96	96	complaint to the department alleging noncompliance with the
97	97	requirements of this subchapter by a health maintenance
98	98	organization, a pharmacy benefit manager that administers pharmacy
99	99	claims for the health maintenance organization, or another entity
100	100	that contracts with the health maintenance organization as provided
101	101	by Section 843.344. A complaint must be submitted in writing or by
102	102	submitting a completed complaint form to the department by mail or
103	103	through another delivery method. The department shall maintain a
104	104	complaint form on the department's Internet website and at the
105	105	department's offices for use by a complainant.
106	106	(c) After investigation of the complaint by the department,
107	107	the commissioner shall determine the validity of the complaint and
108	108	shall enter a written order. In the order, the commissioner shall
109	109	provide the health maintenance organization and the complainant
110	110	with:
111	111	(1) a summary of the investigation conducted by the
112	112	department;
113	113	(2) written notice of the matters asserted, including
114	114	a statement:
115	115	(A) of the legal authority, jurisdiction, and
116	116	alleged conduct under which an enforcement action is imposed or
117	117	denied, with a reference to the statutes and rules involved; and
118	118	(B) that, on request to the department, the
119	119	health maintenance organization and the complainant are entitled to
120	120	a hearing conducted by the State Office of Administrative Hearings
121	121	in the manner prescribed by Section 843.355 regarding the
122	122	determinations made in the order; and
123	123	(3) a determination of the denial of the allegations
124	124	or the imposition of penalties against the health maintenance
125	125	organization.
126	126	(d) An order issued under Subsection (c) is final in the
127	127	absence of a request by the complainant or health maintenance
128	128	organization for a hearing under Section 843.355.
129	129	(e) If the department investigation substantiates the
130	130	allegations of noncompliance made under Subsection (b), the
131	131	commissioner, after notice and an opportunity for a hearing as
132	132	described by Subsection (c), shall require the health maintenance
133	133	organization to pay penalties as provided by Section 843.342.
134	134	Sec. 843.355. HEARING BY STATE OFFICE OF ADMINISTRATIVE
135	135	HEARINGS; FINAL ORDER. (a) The State Office of Administrative
136	136	Hearings shall conduct a hearing regarding a written order of the
137	137	commissioner under Section 843.354 on the request of the
138	138	department. A hearing under this section is subject to Chapter
139	139	2001, Government Code, and shall be conducted as a contested case
140	140	hearing.
141	141	(b) After receipt of a proposal for decision issued by the
142	142	State Office of Administrative Hearings after a hearing conducted
143	143	under Subsection (a), the commissioner shall issue a final order.
144	144	(c) If it appears to the department, the complainant, or the
145	145	health maintenance organization that a person or entity is engaging
146	146	in or is about to engage in a violation of a final order issued under
147	147	Subsection (b), the department, the complainant, or the health
148	148	maintenance organization may bring an action for judicial review in
149	149	district court in Travis County to enjoin or restrain the
150	150	continuation or commencement of the violation or to compel
151	151	compliance with the final order. The complainant or the health
152	152	maintenance organization may also bring an action for judicial
153	153	review of the final order.
154	154	Sec. 843.356. LEGISLATIVE DECLARATION. It is the intent of
155	155	the legislature that the requirements contained in this subchapter
156	156	regarding payment of claims to providers who are pharmacists or
157	157	pharmacies apply to all health maintenance organizations and
158	158	pharmacy benefit managers unless otherwise prohibited by federal
159	159	law.
160	160	SECTION 7. Section 1301.001, Insurance Code, is amended by
161	161	amending Subdivision (1) and adding Subdivision (1-a) to read as
162	162	follows:
163	163	(1) "Extrapolation" means a mathematical process or
164	164	technique used by an insurer or pharmacy benefit manager that
165	165	administers pharmacy claims for an insurer in the audit of a
166	166	pharmacy or pharmacist to estimate audit results or findings for a
167	167	larger batch or group of claims not reviewed by the insurer or
168	168	pharmacy benefit manager.
169	169	(1-a) "Health care provider" means a practitioner,
170	170	institutional provider, or other person or organization that
171	171	furnishes health care services and that is licensed or otherwise
172	172	authorized to practice in this state. The term includes a
173	173	pharmacist and a pharmacy. The term does not include a physician.
174	174	SECTION 8. Section 1301.103, Insurance Code, is amended to
175	175	read as follows:
176	176	Sec. 1301.103. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except
177	177	as provided by Sections 1301.104 and [Section] 1301.1054, not later
178	178	than the 45th day after the date an insurer receives a clean claim
179	179	from a preferred provider in a nonelectronic format or the 30th day
180	180	after the date an insurer receives a clean claim from a preferred
181	181	provider that is electronically submitted, the insurer shall make a
182	182	determination of whether the claim is payable and:
183	183	(1) if the insurer determines the entire claim is
184	184	payable, pay the total amount of the claim in accordance with the
185	185	contract between the preferred provider and the insurer;
186	186	(2) if the insurer determines a portion of the claim is
187	187	payable, pay the portion of the claim that is not in dispute and
188	188	notify the preferred provider in writing why the remaining portion
189	189	of the claim will not be paid; or
190	190	(3) if the insurer determines that the claim is not
191	191	payable, notify the preferred provider in writing why the claim
192	192	will not be paid.
193	193	SECTION 9. Section 1301.104, Insurance Code, is amended to
194	194	read as follows:
195	195	Sec. 1301.104. DEADLINE FOR ACTION ON CERTAIN PHARMACY
196	196	CLAIMS; PAYMENT. (a) An [Not later than the 21st day after the date
197	197	an] insurer, or a pharmacy benefit manager that administers
198	198	pharmacy claims for the insurer under a preferred provider benefit
199	199	plan, that affirmatively adjudicates a pharmacy claim that is
200	200	electronically submitted, [the insurer] shall pay the total amount
201	201	of the claim through electronic funds transfer not later than the
202	202	14th day after the date on which the claim was affirmatively
203	203	adjudicated.
204	204	(b) An insurer, or a pharmacy benefit manager that
205	205	administers pharmacy claims for the insurer under a preferred
206	206	provider benefit plan, that affirmatively adjudicates a pharmacy
207	207	claim that is not electronically submitted, shall pay the total
208	208	amount of the claim not later than the 21st day after the date on
209	209	which the claim was affirmatively adjudicated.
210	210	SECTION 10. Section 1301.105, Insurance Code, is amended by
211	211	adding Subsections (e) and (f) to read as follows:
212	212	(e) An insurer or a pharmacy benefit manager that
213	213	administers pharmacy claims for the insurer may not use
214	214	extrapolation to complete the audit of a preferred provider that is
215	215	a pharmacist or pharmacy. An insurer may not require extrapolation
216	216	audits as a condition of participation in the insurer's contract,
217	217	network, or program for a preferred provider that is a pharmacist or
218	218	pharmacy.
219	219	(f) An insurer or a pharmacy benefit manager that
220	220	administers pharmacy claims for the insurer that performs an
221	221	on-site audit of a preferred provider that is a pharmacist or
222	222	pharmacy shall provide the provider reasonable notice of the audit
223	223	and accommodate the provider's schedule to the greatest extent
224	224	possible. The notice required under this subsection must be in
225	225	writing and must be sent by certified mail to the preferred provider
226	226	not later than the 15th day before the date on which the on-site
227	227	audit is scheduled to occur.
228	228	SECTION 11. Section 1301.109, Insurance Code, is amended to
229	229	read as follows:
230	230	Sec. 1301.109. APPLICABILITY TO ENTITIES CONTRACTING WITH
231	231	INSURER. This subchapter applies to a person, including a pharmacy
232	232	benefit manager, with whom an insurer contracts to:
233	233	(1) process or pay claims;
234	234	(2) obtain the services of physicians and health care
235	235	providers to provide health care services to insureds; or
236	236	(3) issue verifications or preauthorizations.
237	237	SECTION 12. Subchapter C-1, Chapter 1301, Insurance Code,
238	238	is amended by adding Sections 1301.139, 1301.140, and 1301.141 to
239	239	read as follows:
240	240	Sec. 1301.139. DEPARTMENT ENFORCEMENT OF PHARMACY CLAIMS.
241	241	(a) Notwithstanding any other provision of this subchapter, a
242	242	dispute regarding payment of a claim to a preferred provider who is
243	243	a pharmacist or pharmacy shall be resolved as provided by this
244	244	section.
245	245	(b) A preferred provider who is a pharmacist or pharmacy may
246	246	submit a complaint to the department alleging noncompliance with
247	247	the requirements of this subchapter by an insurer, a pharmacy
248	248	benefit manager that administers pharmacy claims for the insurer,
249	249	or another entity that contracts with the insurer as provided by
250	250	Section 1301.109. A complaint must be submitted in writing or by
251	251	submitting a completed complaint form to the department by mail or
252	252	through another delivery method. The department shall maintain a
253	253	complaint form on the department's Internet website and at the
254	254	department's offices for use by a complainant.
255	255	(c) After investigation of the complaint by the department,
256	256	the commissioner shall determine the validity of the complaint and
257	257	shall enter a written order. In the order, the commissioner shall
258	258	provide the insurer and the complainant with:
259	259	(1) a summary of the investigation conducted by the
260	260	department;
261	261	(2) written notice of the matters asserted, including
262	262	a statement:
263	263	(A) of the legal authority, jurisdiction, and
264	264	alleged conduct under which an enforcement action is imposed or
265	265	denied, with a reference to the statutes and rules involved; and
266	266	(B) that, on request to the department, the
267	267	insurer and the complainant are entitled to a hearing conducted by
268	268	the State Office of Administrative Hearings in the manner
269	269	prescribed by Section 1301.140 regarding the determinations made in
270	270	the order; and
271	271	(3) a determination of the denial of the allegations
272	272	or the imposition of penalties against the insurer.
273	273	(d) An order issued under Subsection (c) is final in the
274	274	absence of a request by the complainant or insurer for a hearing
275	275	under Section 1301.140.
276	276	(e) If the department investigation substantiates the
277	277	allegations of noncompliance made under Subsection (b), the
278	278	commissioner, after notice and an opportunity for a hearing as
279	279	described by Subsection (c), shall require the insurer to pay
280	280	penalties as provided by Section 1301.137.
281	281	Sec. 1301.140. HEARING BY STATE OFFICE OF ADMINISTRATIVE
282	282	HEARINGS; FINAL ORDER. (a) The State Office of Administrative
283	283	Hearings shall conduct a hearing regarding a written order of the
284	284	commissioner under Section 1301.139 on the request of the
285	285	department. A hearing under this section is subject to Chapter
286	286	2001, Government Code, and shall be conducted as a contested case
287	287	hearing.
288	288	(b) After receipt of a proposal for decision issued by the
289	289	State Office of Administrative Hearings after a hearing conducted
290	290	under Subsection (a), the commissioner shall issue a final order.
291	291	(c) If it appears to the department, the complainant, or the
292	292	insurer that a person or entity is engaging in or is about to engage
293	293	in a violation of a final order issued under Subsection (b), the
294	294	department, the complainant, or the insurer may bring an action for
295	295	judicial review in district court in Travis County to enjoin or
296	296	restrain the continuation or commencement of the violation or to
297	297	compel compliance with the final order. The complainant or the
298	298	insurer may also bring an action for judicial review of the final
299	299	order.
300	300	Sec. 1301.141. LEGISLATIVE DECLARATION. It is the intent
301	301	of the legislature that the requirements contained in this
302	302	subchapter regarding payment of claims to preferred providers who
303	303	are pharmacists or pharmacies apply to all insurers and pharmacy
304	304	benefit managers unless otherwise prohibited by federal law.
305	305	SECTION 13. The change in law made by this Act applies only
306	306	to a claim submitted by a provider to a health maintenance
307	307	organization or an insurer on or after the effective date of this
308	308	Act. A claim submitted before the effective date of this Act is
309	309	governed by the law as it existed immediately before that date, and
310	310	that law is continued in effect for that purpose.
311	311	SECTION 14. The change in law made by this Act applies only
312	312	to a contract between a pharmacy benefit manager and an insurer or
313	313	health maintenance organization entered into or renewed on or after
314	314	January 1, 2010. A contract entered into or renewed before January
315	315	1, 2010, is governed by the law as it existed immediately before the
316	316	effective date of this Act, and that law is continued in effect for
317	317	that purpose.
318	318	SECTION 15. This Act takes effect September 1, 2009.