81R5675 KCR-F
By: Leibowitz H.B. No. 3822
A BILL TO BE ENTITLED
AN ACT
relating to review of the medical necessity of certain health care
provided in connection with a workers' compensation claim.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter B, Chapter 413, Labor Code, is
amended by adding Section 413.0142 to read as follows:
Sec. 413.0142. WAIVER OF CERTAIN INSURER CHALLENGES. (a)
Regarding a specific treatment or service approved in the
preauthorization process, an insurance carrier waives the right to
raise a future challenge alleging that an injury sustained by an
injured employee is not compensable or that health care provided to
an injured employee was not related to a compensable injury if:
(1) the insurance carrier does not include the
compensability of the injury or that the health care provided to the
injured employee was not related to a compensable injury as a basis
for an initial denial of a request for preauthorization or the
denial of reconsideration of coverage; and
(2) the requested treatment or service is ultimately
determined through a medical dispute resolution proceeding to be
health care reasonably required under this subtitle.
(b) This section may not be construed as limiting an
insurance carrier's ability to challenge compensability or the
relatedness to a compensable injury of provided health care if the
challenge concerns income benefits or medical benefits not included
in the preauthorization request.
(c) If the insurance carrier raises a compensability or
relatedness issue in a denial of preauthorization, that issue must
be considered and resolved in the same proceeding that addresses
the issue of whether the requested treatment or service is health
care reasonably required under this subtitle.
SECTION 2. Section 413.031(d), Labor Code, is amended to
read as follows:
(d) A review of the medical necessity of a health care
service requiring preauthorization under Section 413.014 or
commissioner rules under that section or Section 413.011(g) shall
be conducted by an independent review organization under Chapter
4202, Insurance Code, in the same manner as reviews of utilization
review decisions by health maintenance organizations. The
independent review organization's decision is limited to whether
the proposed treatment or service is health care reasonably
required for the injury. The independent review organization may
not consider issues relating to allegations as to whether the
injury in question is compensable or that the health care provided
to the injured employee was not related to the compensable injury.
It is a defense for the insurance carrier if the carrier timely
complies with the decision of the independent review organization.
SECTION 3. The change in law made by this Act applies only
to a claim for workers' compensation benefits based on a
compensable injury that occurs on or after the effective date of
this Act. A claim based on a compensable injury that occurs before
that date is governed by the law in effect on the date the
compensable injury occurred, and the former law is continued in
effect for that purpose.
SECTION 4. This Act takes effect September 1, 2009.