Texas 2011 - 82nd Regular

Texas House Bill HB2292 Compare Versions

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1	1	By: Hunter, Hopson (Senate Sponsor - Van de Putte) H.B. No. 2292
2	2	(In the Senate - Received from the House May 16, 2011;
3	3	May 16, 2011, read first time and referred to Committee on State
4	4	Affairs; May 19, 2011, reported favorably by the following vote:
5	5	Yeas 8, Nays 0; May 19, 2011, sent to printer.)
6	6
7	7
8	8	A BILL TO BE ENTITLED
9	9	AN ACT
10	10	relating to payment of claims to pharmacies and pharmacists.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Section 843.002, Insurance Code, is amended by
13	13	amending Subdivision (9-a) and adding Subdivision (9-b) to read as
14	14	follows:
15	15	(9-a) "Extrapolation" means a mathematical process or
16	16	technique used by a health maintenance organization or pharmacy
17	17	benefit manager that administers pharmacy claims for a health
18	18	maintenance organization in the audit of a pharmacy or pharmacist
19	19	to estimate audit results or findings for a larger batch or group of
20	20	claims not reviewed by the health maintenance organization or
21	21	pharmacy benefit manager.
22	22	(9-b) "Freestanding emergency medical care facility"
23	23	means a facility licensed under Chapter 254, Health and Safety
24	24	Code.
25	25	SECTION 2. Section 843.338, Insurance Code, is amended to
26	26	read as follows:
27	27	Sec. 843.338. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except
28	28	as provided by Sections [Section] 843.3385 and 843.339, not later
29	29	than the 45th day after the date on which a health maintenance
30	30	organization receives a clean claim from a participating physician
31	31	or provider in a nonelectronic format or the 30th day after the date
32	32	the health maintenance organization receives a clean claim from a
33	33	participating physician or provider that is electronically
34	34	submitted, the health maintenance organization shall make a
35	35	determination of whether the claim is payable and:
36	36	(1) if the health maintenance organization determines
37	37	the entire claim is payable, pay the total amount of the claim in
38	38	accordance with the contract between the physician or provider and
39	39	the health maintenance organization;
40	40	(2) if the health maintenance organization determines
41	41	a portion of the claim is payable, pay the portion of the claim that
42	42	is not in dispute and notify the physician or provider in writing
43	43	why the remaining portion of the claim will not be paid; or
44	44	(3) if the health maintenance organization determines
45	45	that the claim is not payable, notify the physician or provider in
46	46	writing why the claim will not be paid.
47	47	SECTION 3. Section 843.339, Insurance Code, is amended to
48	48	read as follows:
49	49	Sec. 843.339. DEADLINE FOR ACTION ON [CERTAIN] PRESCRIPTION
50	50	CLAIMS; PAYMENT. (a) A [Not later than the 21st day after the date
51	51	a] health maintenance organization, or a pharmacy benefit manager
52	52	that administers pharmacy claims for the health maintenance
53	53	organization, that affirmatively adjudicates a pharmacy claim that
54	54	is electronically submitted[, the health maintenance organization]
55	55	shall pay the total amount of the claim through electronic funds
56	56	transfer not later than the 18th day after the date on which the
57	57	claim was affirmatively adjudicated.
58	58	(b) A health maintenance organization, or a pharmacy
59	59	benefit manager that administers pharmacy claims for the health
60	60	maintenance organization, that affirmatively adjudicates a
61	61	pharmacy claim that is not electronically submitted shall pay the
62	62	total amount of the claim not later than the 21st day after the date
63	63	on which the claim was affirmatively adjudicated.
64	64	SECTION 4. Subchapter J, Chapter 843, Insurance Code, is
65	65	amended by adding Section 843.3401 to read as follows:
66	66	Sec. 843.3401. AUDIT OF PHARMACIST OR PHARMACY. (a) A
67	67	health maintenance organization or a pharmacy benefit manager that
68	68	administers pharmacy claims for the health maintenance
69	69	organization may not use extrapolation to complete the audit of a
70	70	provider who is a pharmacist or pharmacy. A health maintenance
71	71	organization may not require extrapolation audits as a condition of
72	72	participation in the health maintenance organization's contract,
73	73	network, or program for a provider who is a pharmacist or pharmacy.
74	74	(b) A health maintenance organization or a pharmacy benefit
75	75	manager that administers pharmacy claims for the health maintenance
76	76	organization that performs an on-site audit under this chapter of a
77	77	provider who is a pharmacist or pharmacy shall provide the provider
78	78	reasonable notice of the audit and accommodate the provider's
79	79	schedule to the greatest extent possible. The notice required
80	80	under this subsection must be in writing and must be sent by
81	81	certified mail to the provider not later than the 15th day before
82	82	the date on which the on-site audit is scheduled to occur.
83	83	SECTION 5. Section 843.344, Insurance Code, is amended to
84	84	read as follows:
85	85	Sec. 843.344. APPLICABILITY OF SUBCHAPTER TO ENTITIES
86	86	CONTRACTING WITH HEALTH MAINTENANCE ORGANIZATION. This subchapter
87	87	applies to a person, including a pharmacy benefit manager, with
88	88	whom a health maintenance organization contracts to:
89	89	(1) process or pay claims;
90	90	(2) obtain the services of physicians and providers to
91	91	provide health care services to enrollees; or
92	92	(3) issue verifications or preauthorizations.
93	93	SECTION 6. Subchapter J, Chapter 843, Insurance Code, is
94	94	amended by adding Section 843.354 to read as follows:
95	95	Sec. 843.354. LEGISLATIVE DECLARATION. It is the intent of
96	96	the legislature that the requirements contained in this subchapter
97	97	regarding payment of claims to providers who are pharmacists or
98	98	pharmacies apply to all health maintenance organizations and
99	99	pharmacy benefit managers unless otherwise prohibited by federal
100	100	law.
101	101	SECTION 7. Section 1301.001, Insurance Code, is amended by
102	102	amending Subdivision (1) and adding Subdivision (1-a) to read as
103	103	follows:
104	104	(1) "Extrapolation" means a mathematical process or
105	105	technique used by an insurer or pharmacy benefit manager that
106	106	administers pharmacy claims for an insurer in the audit of a
107	107	pharmacy or pharmacist to estimate audit results or findings for a
108	108	larger batch or group of claims not reviewed by the insurer or
109	109	pharmacy benefit manager.
110	110	(1-a) "Health care provider" means a practitioner,
111	111	institutional provider, or other person or organization that
112	112	furnishes health care services and that is licensed or otherwise
113	113	authorized to practice in this state. The term includes a
114	114	pharmacist and a pharmacy. The term does not include a physician.
115	115	SECTION 8. Section 1301.103, Insurance Code, is amended to
116	116	read as follows:
117	117	Sec. 1301.103. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except
118	118	as provided by Sections 1301.104 and [Section] 1301.1054, not later
119	119	than the 45th day after the date an insurer receives a clean claim
120	120	from a preferred provider in a nonelectronic format or the 30th day
121	121	after the date an insurer receives a clean claim from a preferred
122	122	provider that is electronically submitted, the insurer shall make a
123	123	determination of whether the claim is payable and:
124	124	(1) if the insurer determines the entire claim is
125	125	payable, pay the total amount of the claim in accordance with the
126	126	contract between the preferred provider and the insurer;
127	127	(2) if the insurer determines a portion of the claim is
128	128	payable, pay the portion of the claim that is not in dispute and
129	129	notify the preferred provider in writing why the remaining portion
130	130	of the claim will not be paid; or
131	131	(3) if the insurer determines that the claim is not
132	132	payable, notify the preferred provider in writing why the claim
133	133	will not be paid.
134	134	SECTION 9. Section 1301.104, Insurance Code, is amended to
135	135	read as follows:
136	136	Sec. 1301.104. DEADLINE FOR ACTION ON [CERTAIN] PHARMACY
137	137	CLAIMS; PAYMENT. (a) An [Not later than the 21st day after the
138	138	date an] insurer, or a pharmacy benefit manager that administers
139	139	pharmacy claims for the insurer under a preferred provider benefit
140	140	plan, that affirmatively adjudicates a pharmacy claim that is
141	141	electronically submitted[, the insurer] shall pay the total amount
142	142	of the claim through electronic funds transfer not later than the
143	143	18th day after the date on which the claim was affirmatively
144	144	adjudicated.
145	145	(b) An insurer, or a pharmacy benefit manager that
146	146	administers pharmacy claims for the insurer under a preferred
147	147	provider benefit plan, that affirmatively adjudicates a pharmacy
148	148	claim that is not electronically submitted shall pay the total
149	149	amount of the claim not later than the 21st day after the date on
150	150	which the claim was affirmatively adjudicated.
151	151	SECTION 10. Subchapter C, Chapter 1301, Insurance Code, is
152	152	amended by adding Section 1301.1041 to read as follows:
153	153	Sec. 1301.1041. AUDIT OF PHARMACIST OR PHARMACY. (a) An
154	154	insurer or a pharmacy benefit manager that administers pharmacy
155	155	claims for the insurer may not use extrapolation to complete the
156	156	audit of a preferred provider that is a pharmacist or pharmacy. An
157	157	insurer may not require extrapolation audits as a condition of
158	158	participation in the insurer's contract, network, or program for a
159	159	preferred provider that is a pharmacist or pharmacy.
160	160	(b) An insurer or a pharmacy benefit manager that
161	161	administers pharmacy claims for the insurer that performs an
162	162	on-site audit of a preferred provider who is a pharmacist or
163	163	pharmacy shall provide the provider reasonable notice of the audit
164	164	and accommodate the provider's schedule to the greatest extent
165	165	possible. The notice required under this subsection must be in
166	166	writing and must be sent by certified mail to the preferred provider
167	167	not later than the 15th day before the date on which the on-site
168	168	audit is scheduled to occur.
169	169	SECTION 11. Section 1301.109, Insurance Code, is amended to
170	170	read as follows:
171	171	Sec. 1301.109. APPLICABILITY TO ENTITIES CONTRACTING WITH
172	172	INSURER. This subchapter applies to a person, including a pharmacy
173	173	benefit manager, with whom an insurer contracts to:
174	174	(1) process or pay claims;
175	175	(2) obtain the services of physicians and health care
176	176	providers to provide health care services to insureds; or
177	177	(3) issue verifications or preauthorizations.
178	178	SECTION 12. Subchapter C-1, Chapter 1301, Insurance Code,
179	179	is amended by adding Section 1301.139 to read as follows:
180	180	Sec. 1301.139. LEGISLATIVE DECLARATION. It is the intent
181	181	of the legislature that the requirements contained in this
182	182	subchapter regarding payment of claims to preferred providers who
183	183	are pharmacists or pharmacies apply to all insurers and pharmacy
184	184	benefit managers unless otherwise prohibited by federal law.
185	185	SECTION 13. (a) With respect to pharmacy benefits provided
186	186	under a contract, the changes in law made by this Act apply only to a
187	187	contract entered into or renewed on or after the effective date of
188	188	this Act and payment for pharmacy benefits provided under the
189	189	contract. A contract entered into before the effective date of this
190	190	Act and not renewed or that was last renewed before the effective
191	191	date of this Act, and payment for pharmacy benefits provided under
192	192	the contract, are governed by the law in effect immediately before
193	193	the effective date of this Act, and that law is continued in effect
194	194	for that purpose.
195	195	(b) With respect to payment for pharmacy benefits not
196	196	provided under a contract to which Subsection (a) of this section
197	197	applies, the changes in law made by this Act apply only to payment
198	198	for benefits provided on or after the effective date of this Act.
199	199	Payment for benefits not subject to Subsection (a) of this section
200	200	and provided before the effective date of this Act is governed by
201	201	the law in effect immediately before the effective date of this Act,
202	202	and that law is continued in effect for that purpose.
203	203	(c) Sections 843.3401 and 1301.1041, Insurance Code, as
204	204	added by this Act, apply to an audit of a pharmacist or pharmacy
205	205	performed on or after the effective date of this Act unless the
206	206	audit is performed under a contract that is entered into before the
207	207	effective date of this Act and that, at the time of the audit, has
208	208	not been renewed or was last renewed before the effective date of
209	209	this Act.
210	210	SECTION 14. This Act takes effect September 1, 2011.
211	211	* * * * *