83R22752 JSL-D
By: Raymond H.B. No. 2731
Substitute the following for H.B. No. 2731:
By: Raymond C.S.H.B. No. 2731
A BILL TO BE ENTITLED
AN ACT
relating to decreasing administrative burdens of Medicaid managed
care for the state, the managed care organizations, and providers
under managed care networks.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 533.0071, Government Code, is amended to
read as follows:
Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The
commission shall make every effort to improve the administration of
contracts with managed care organizations. To improve the
administration of these contracts, the commission shall:
(1) ensure that the commission has appropriate
expertise and qualified staff to effectively manage contracts with
managed care organizations under the Medicaid managed care program;
(2) evaluate options for Medicaid payment recovery
from managed care organizations if the enrollee dies or is
incarcerated or if an enrollee is enrolled in more than one state
program or is covered by another liable third party insurer;
(3) maximize Medicaid payment recovery options by
contracting with private vendors to assist in the recovery of
capitation payments, payments from other liable third parties, and
other payments made to managed care organizations with respect to
enrollees who leave the managed care program;
(4) decrease the administrative burdens of managed
care for the state, the managed care organizations, and the
providers under managed care networks to the extent that those
changes are compatible with state law and existing Medicaid managed
care contracts, including decreasing those burdens by:
(A) where possible, decreasing the duplication
of administrative reporting requirements for the managed care
organizations, such as requirements for the submission of encounter
data, quality reports, historically underutilized business
reports, and claims payment summary reports;
(B) allowing managed care organizations to
provide updated address information directly to the commission for
correction in the state system;
(C) promoting consistency and uniformity among
managed care organization policies, including policies relating to
the [preauthorization process,] lengths of hospital stays, filing
deadlines, levels of care, and case management services;
(D) developing uniform efficiency standards and
requirements for managed care organizations for the submission and
tracking of preauthorization requests for services provided under
the Medicaid program [reviewing the appropriateness of primary
care case management requirements in the admission and clinical
criteria process, such as requirements relating to including a
separate cover sheet for all communications, submitting
handwritten communications instead of electronic or typed review
processes, and admitting patients listed on separate
notifications]; [and]
(E) providing a [single] portal through which
providers in any managed care organization's provider network may:
(i) submit electronic claims, prior
authorization requests, claims appeals, and reconsiderations,
clinical data, and other documentation that the managed care
organization requests for prior authorization and claims
processing; and
(ii) obtain electronic remittance advice,
explanation of benefits statements, and other standardized
reports; [and]
(F) requiring the use of standardized
application processes and forms for prompt credentialing of
providers in a managed care organization's network; and
(G) promoting prompt and accurate adjudication
of claims through:
(i) provider education on the proper
submission of clean claims and on appeals;
(ii) acceptance of uniform forms, including
the Centers for Medicare and Medicaid Services Forms 1500 and
UB-92, through an electronic portal; and
(iii) the establishment of standards for
claims payments in accordance with a provider's contract;
(5) reserve the right to amend the managed care
organization's process for resolving provider appeals of denials
based on medical necessity to include an independent review process
established by the commission for final determination of these
disputes;
(6) monitor and evaluate a managed care organization's
compliance with contractual requirements regarding:
(A) the reduction of administrative burdens for
network providers; and
(B) complaints regarding claims adjudication or
payment;
(7) measure the rates of retention by managed care
organizations of significant traditional providers; and
(8) develop adequate and clearly defined provider
network standards that are specific to provider type and that
ensure choice among multiple providers to the greatest extent
possible.
SECTION 2. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 3. This Act takes effect September 1, 2013.