Texas 2015 - 84th Regular

Texas House Bill HB1433 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	84R4909 PMO-F
2	2	By: Smithee H.B. No. 1433
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to prompt payment of health care claims, including payment
8	8	for immunizations, vaccines, and serums.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subchapter A, Chapter 16, Civil Practice and
11	11	Remedies Code, is amended by adding Section 16.013 to read as
12	12	follows:
13	13	Sec. 16.013. PROMPT PAYMENT OF HEALTH CARE CLAIMS. A person
14	14	must bring a suit for failure to pay a clean claim in accordance
15	15	with Subchapter J, Chapter 843, or Subchapter C, Chapter 1301,
16	16	Insurance Code, not later than two years after the day the cause of
17	17	action accrues. The cause of action accrues on the latest date
18	18	provided by the applicable subchapter for determining whether the
19	19	claim is payable and making the appropriate payment or
20	20	notification.
21	21	SECTION 2. Section 843.337(a), Insurance Code, is amended
22	22	to read as follows:
23	23	(a) A physician or provider must submit a claim for health
24	24	care services to a health maintenance organization not later than
25	25	the 95th day after the date the physician or provider provides the
26	26	health care services for which the claim is made. A health
27	27	maintenance organization shall accept as proof of timely filing:
28	28	(1) a claim filed in compliance with Subsection (e);
29	29	or
30	30	(2) information from another health maintenance
31	31	organization or any insurer authorized or eligible to engage in the
32	32	business of insurance in this state showing that the physician or
33	33	provider submitted the claim for health care services to the health
34	34	maintenance organization or insurer in compliance with Subsection
35	35	(e).
36	36	SECTION 3. Sections 843.342(a), (b), (d), and (e),
37	37	Insurance Code, are amended to read as follows:
38	38	(a) Except as provided by this section, if a clean claim
39	39	submitted to a health maintenance organization is payable and the
40	40	health maintenance organization does not determine under this
41	41	subchapter that the claim is payable and pay the claim on or before
42	42	the date the health maintenance organization is required to make a
43	43	determination or adjudication of the claim, the health maintenance
44	44	organization shall pay the physician or provider making the claim
45	45	the contracted rate owed on the claim plus a penalty in the amount
46	46	of the lesser of:
47	47	(1) 50 percent of the difference between the billed
48	48	charges, as submitted on the claim, and the contracted rate; or
49	49	(2) $5,000 [$100,000].
50	50	(b) If the claim is paid on or after the 46th day and before
51	51	the 91st day after the date the health maintenance organization is
52	52	required to make a determination or adjudication of the claim, the
53	53	health maintenance organization shall pay a penalty in the amount
54	54	of the lesser of:
55	55	(1) 100 percent of the difference between the billed
56	56	charges, as submitted on the claim, and the contracted rate; or
57	57	(2) $10,000 [$200,000].
58	58	(d) Except as provided by this section, a health maintenance
59	59	organization that determines under this subchapter that a claim is
60	60	payable, pays only a portion of the amount of the claim on or before
61	61	the date the health maintenance organization is required to make a
62	62	determination or adjudication of the claim, and pays the balance of
63	63	the contracted rate owed for the claim after that date shall pay to
64	64	the physician or provider, in addition to the contracted amount
65	65	owed, a penalty on the amount not timely paid in the amount of the
66	66	lesser of:
67	67	(1) 50 percent of the underpaid amount; or
68	68	(2) $5,000 [$100,000].
69	69	(e) If the balance of the claim is paid on or after the 46th
70	70	day and before the 91st day after the date the health maintenance
71	71	organization is required to make a determination or adjudication of
72	72	the claim, the health maintenance organization shall pay a penalty
73	73	on the balance of the claim in the amount of the lesser of:
74	74	(1) 100 percent of the underpaid amount; or
75	75	(2) $10,000 [$200,000].
76	76	SECTION 4. Subchapter J, Chapter 843, Insurance Code, is
77	77	amended by adding Section 843.3421 to read as follows:
78	78	Sec. 843.3421. PAYMENT APPEAL DEADLINE. If a contract
79	79	between a health maintenance organization and a physician or
80	80	provider directly or indirectly requires that a contractual dispute
81	81	regarding a post-service payment denial or payment dispute be
82	82	appealed, the health maintenance organization may not impose a
83	83	deadline for filing the appeal that is less than 180 days after the
84	84	earlier of:
85	85	(1) the date of the initial payment or denial notice;
86	86	or
87	87	(2) the latest date for making a payment or
88	88	notification with respect to the claim under this subchapter.
89	89	SECTION 5. Subchapter J, Chapter 843, Insurance Code, is
90	90	amended by adding Section 843.355 to read as follows:
91	91	Sec. 843.355. PAYMENT FOR IMMUNIZATIONS, VACCINES, AND
92	92	SERUMS. (a) A contract between a health maintenance organization
93	93	and a physician or provider must disclose the source of the
94	94	information used to calculate a fee payment for an immunization,
95	95	vaccine, or serum. The information must be made readily accessible
96	96	to the physician or provider, and the contract must include an
97	97	explanation of how the physician or provider may access the
98	98	information.
99	99	(b) Notwithstanding Section 843.321(a)(3), a health
100	100	maintenance organization is not required to notify a physician or
101	101	provider, and a contract between a health maintenance organization
102	102	and a physician or provider may not directly or indirectly require
103	103	the health maintenance organization to notify the physician or
104	104	provider, before a change in a fee payment described by Subsection
105	105	(a) takes effect if the payment change results from a change in
106	106	information described by Subsection (a), the source of which is a
107	107	third party not controlled by the health maintenance organization,
108	108	such as the Centers for Disease Control Vaccine Price List.
109	109	(c) A contract between a health maintenance organization
110	110	and a physician or provider must require the health maintenance
111	111	organization to provide notice of a change of a source of
112	112	information described by Subsection (a) used to calculate the fee
113	113	payment for an immunization, vaccine, or serum not later than the
114	114	90th day before the date the change of source takes effect.
115	115	SECTION 6. Section 1301.102(c), Insurance Code, is amended
116	116	to read as follows:
117	117	(c) An insurer shall accept as proof of timely filing of a
118	118	claim for medical care or health care services:
119	119	(1) a claim filed in compliance with Subsection (b);
120	120	or
121	121	(2) information from any [another] insurer authorized
122	122	or eligible to engage in the business of insurance in this state or
123	123	health maintenance organization showing that the physician or
124	124	health care provider submitted the claim for medical care or health
125	125	care services to the insurer or health maintenance organization in
126	126	compliance with Subsection (b).
127	127	SECTION 7. Sections 1301.137(a), (b), (d), and (e),
128	128	Insurance Code, are amended to read as follows:
129	129	(a) Except as provided by this section, if a clean claim
130	130	submitted to an insurer is payable and the insurer does not
131	131	determine under Subchapter C that the claim is payable and pay the
132	132	claim on or before the date the insurer is required to make a
133	133	determination or adjudication of the claim, the insurer shall pay
134	134	the preferred provider making the claim the contracted rate owed on
135	135	the claim plus a penalty in the amount of the lesser of:
136	136	(1) 50 percent of the difference between the billed
137	137	charges, as submitted on the claim, and the contracted rate; or
138	138	(2) $5,000 [$100,000].
139	139	(b) If the claim is paid on or after the 46th day and before
140	140	the 91st day after the date the insurer is required to make a
141	141	determination or adjudication of the claim, the insurer shall pay a
142	142	penalty in the amount of the lesser of:
143	143	(1) 100 percent of the difference between the billed
144	144	charges, as submitted on the claim, and the contracted rate; or
145	145	(2) $10,000 [$200,000].
146	146	(d) Except as provided by this section, an insurer that
147	147	determines under Subchapter C that a claim is payable, pays only a
148	148	portion of the amount of the claim on or before the date the insurer
149	149	is required to make a determination or adjudication of the claim,
150	150	and pays the balance of the contracted rate owed for the claim after
151	151	that date shall pay to the preferred provider, in addition to the
152	152	contracted amount owed, a penalty on the amount not timely paid in
153	153	the amount of the lesser of:
154	154	(1) 50 percent of the underpaid amount; or
155	155	(2) $5,000 [$100,000].
156	156	(e) If the balance of the claim is paid on or after the 46th
157	157	day and before the 91st day after the date the insurer is required
158	158	to make a determination or adjudication of the claim, the insurer
159	159	shall pay a penalty on the balance of the claim in the amount of the
160	160	lesser of:
161	161	(1) 100 percent of the underpaid amount; or
162	162	(2) $10,000 [$200,000].
163	163	SECTION 8. Subchapter C-1, Chapter 1301, Insurance Code, is
164	164	amended by adding Section 1301.1371 to read as follows:
165	165	Sec. 1301.1371. PAYMENT APPEAL DEADLINE. If a contract
166	166	between an insurer and a preferred provider directly or indirectly
167	167	requires that a contractual dispute regarding a post-service
168	168	payment denial or payment dispute be appealed, the insurer may not
169	169	impose a deadline for filing the appeal that is less than 180 days
170	170	after the earlier of:
171	171	(1) the date of the initial payment or denial notice;
172	172	or
173	173	(2) the latest date for making a payment or
174	174	notification with respect to the claim under Subchapter C.
175	175	SECTION 9. Subchapter C-1, Chapter 1301, Insurance Code, is
176	176	amended by adding Section 1301.140 to read as follows:
177	177	Sec. 1301.140. PAYMENT FOR IMMUNIZATIONS, VACCINES, AND
178	178	SERUMS. (a) A contract between an insurer and a preferred provider
179	179	must disclose the source of the information used to calculate a fee
180	180	payment for an immunization, vaccine, or serum. The information
181	181	must be made readily accessible to the preferred provider, and the
182	182	contract must include an explanation of how the preferred provider
183	183	may access the information.
184	184	(b) Notwithstanding Section 1301.136(a)(3), an insurer is
185	185	not required to notify a preferred provider, and a contract between
186	186	an insurer and a preferred provider may not directly or indirectly
187	187	require the insurer to notify the preferred provider, before a
188	188	change in a fee payment described by Subsection (a) takes effect if
189	189	the payment change results from a change in information described
190	190	by Subsection (a), the source of which is a third party not
191	191	controlled by the insurer, such as the Centers for Disease Control
192	192	Vaccine Price List.
193	193	(c) A contract between an insurer and a preferred provider
194	194	must require the insurer to provide notice of a change of a source
195	195	of information described by Subsection (a) used to calculate the
196	196	fee payment for an immunization, vaccine, or serum not later than
197	197	the 90th day before the date the change takes effect.
198	198	SECTION 10. Sections 843.342(m) and 1301.137(l), Insurance
199	199	Code, are repealed.
200	200	SECTION 11. It is the intent of the legislature that Section
201	201	16.013, Civil Practice and Remedies Code, as added by this Act,
202	202	applies only to a personal cause of action and does not limit or
203	203	modify the jurisdiction and authority of the commissioner of
204	204	insurance to enforce the prompt payment requirements of Chapters
205	205	843 and 1301, Insurance Code.
206	206	SECTION 12. (a) Section 16.013, Civil Practice and
207	207	Remedies Code, as added by this Act, applies only to a cause of
208	208	action arising from a claim submitted on or after the effective date
209	209	of this Act. A cause of action arising from a claim submitted
210	210	before the effective date of this Act is governed by the law
211	211	applicable to the claim immediately before the effective date of
212	212	this Act, and that law is continued in effect for that purpose.
213	213	(b) Except as provided by Subsection (c) of this section,
214	214	Sections 843.337, 843.342, 1301.102, and 1301.137, Insurance Code,
215	215	as amended by this Act, apply only to a claim submitted on or after
216	216	the effective date of this Act. A claim submitted before the
217	217	effective date of this Act is governed by the law as it existed
218	218	immediately before the effective date of this Act, and that law is
219	219	continued in effect for that purpose.
220	220	(c) With respect to a claim submitted under a contract with
221	221	a health maintenance organization or insurer, Sections 843.337,
222	222	843.342, 1301.102, and 1301.137, Insurance Code, as amended by this
223	223	Act, apply only to a claim submitted under a contract entered into
224	224	or renewed on or after the effective date of this Act. A claim
225	225	submitted under a contract entered into or renewed before the
226	226	effective date of this Act is governed by the law as it existed
227	227	immediately before the effective date of this Act, and that law is
228	228	continued in effect for that purpose.
229	229	(d) Sections 843.3421, 843.355, 1301.1371, and 1301.140,
230	230	Insurance Code, as added by this Act, apply only to a contract
231	231	entered into or renewed on or after the effective date of this Act.
232	232	A contract entered into or renewed before the effective date of this
233	233	Act is governed by the law as it existed immediately before the
234	234	effective date of this Act, and that law is continued in effect for
235	235	that purpose.
236	236	SECTION 13. This Act takes effect September 1, 2015.