By: Hinojosa, Schwertner S.B. No. 1150
(In the Senate - Filed March 5, 2013; March 12, 2013, read
first time and referred to Committee on Health and Human Services;
May 6, 2013, reported adversely, with favorable Committee
Substitute by the following vote: Yeas 9, Nays 0; May 6, 2013,
sent to printer.)
COMMITTEE SUBSTITUTE FOR S.B. No. 1150 By: Zaffirini
A BILL TO BE ENTITLED
AN ACT
relating to a provider protection plan that ensures efficiency and
reduces administrative burdens on providers participating in a
Medicaid managed care model or arrangement.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.0055 to read as follows:
Sec. 533.0055. PROVIDER PROTECTION PLAN. (a) The
commission shall develop and implement a provider protection plan
that is designed to reduce administrative burdens placed on
providers participating in a Medicaid managed care model or
arrangement implemented under this chapter and to ensure efficiency
in provider enrollment and reimbursement. The commission shall
incorporate the measures identified in the plan, to the greatest
extent possible, into each contract between a managed care
organization and the commission for the provision of health care
services to recipients.
(b) The provider protection plan required under this
section must provide for:
(1) prompt payment and proper reimbursement of
providers by managed care organizations;
(2) prompt and accurate adjudication of claims
through:
(A) provider education on the proper submission
of clean claims and on appeals;
(B) acceptance of uniform forms, including HCFA
Forms 1500 and UB-92 and subsequent versions of those forms,
through an electronic portal; and
(C) the establishment of standards for claims
payments in accordance with a provider's contract;
(3) adequate and clearly defined provider network
standards that are specific to provider type, including physicians,
general acute care facilities, and other provider types defined in
the commission's network adequacy standards in effect on January 1,
2013, and that ensure choice among multiple providers to the
greatest extent possible;
(4) a prompt credentialing process for providers;
(5) uniform efficiency standards and requirements for
managed care organizations for the submission and tracking of
preauthorization requests for services provided under the Medicaid
program;
(6) establishment of an electronic process, including
the use of an Internet portal, through which providers in any
managed care organization's provider network may:
(A) 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
(B) obtain electronic remittance advice,
explanation of benefits statements, and other standardized
reports;
(7) the measurement of the rates of retention by
managed care organizations of significant traditional providers;
(8) the creation of a work group to review and make
recommendations to the commission concerning any requirement under
this subsection for which immediate implementation is not feasible
at the time the plan is otherwise implemented, including the
required process for submission and acceptance of attachments for
claims processing and prior authorization requests through an
electronic process under Subdivision (6) and, for any requirement
that is not implemented immediately, recommendations regarding the
expected:
(A) fiscal impact of implementing the
requirement; and
(B) timeline for implementation of the
requirement; and
(9) any other provision that the commission determines
will ensure efficiency or reduce administrative burdens on
providers participating in a Medicaid managed care model or
arrangement.
SECTION 2. As soon as possible, but not later than September
1, 2014, the Health and Human Services Commission shall implement
the provider protection plan required under Section 533.0055,
Government Code, as added by this Act.
SECTION 3. 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 4. This Act takes effect September 1, 2013.
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