84R4909 PMO-F
By: Smithee H.B. No. 1433
A BILL TO BE ENTITLED
AN ACT
relating to prompt payment of health care claims, including payment
for immunizations, vaccines, and serums.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 16, Civil Practice and
Remedies Code, is amended by adding Section 16.013 to read as
follows:
Sec. 16.013. PROMPT PAYMENT OF HEALTH CARE CLAIMS. A person
must bring a suit for failure to pay a clean claim in accordance
with Subchapter J, Chapter 843, or Subchapter C, Chapter 1301,
Insurance Code, not later than two years after the day the cause of
action accrues. The cause of action accrues on the latest date
provided by the applicable subchapter for determining whether the
claim is payable and making the appropriate payment or
notification.
SECTION 2. Section 843.337(a), Insurance Code, is amended
to read as follows:
(a) A physician or provider must submit a claim for health
care services to a health maintenance organization not later than
the 95th day after the date the physician or provider provides the
health care services for which the claim is made. A health
maintenance organization shall accept as proof of timely filing:
(1) a claim filed in compliance with Subsection (e);
or
(2) information from another health maintenance
organization or any insurer authorized or eligible to engage in the
business of insurance in this state showing that the physician or
provider submitted the claim for health care services to the health
maintenance organization or insurer in compliance with Subsection
(e).
SECTION 3. Sections 843.342(a), (b), (d), and (e),
Insurance Code, are amended to read as follows:
(a) Except as provided by this section, if a clean claim
submitted to a health maintenance organization is payable and the
health maintenance organization does not determine under this
subchapter that the claim is payable and pay the claim on or before
the date the health maintenance organization is required to make a
determination or adjudication of the claim, the health maintenance
organization shall pay the physician or provider making the claim
the contracted rate owed on the claim plus a penalty in the amount
of the lesser of:
(1) 50 percent of the difference between the billed
charges, as submitted on the claim, and the contracted rate; or
(2) $5,000 [$100,000].
(b) If the claim is paid on or after the 46th day and before
the 91st day after the date the health maintenance organization is
required to make a determination or adjudication of the claim, the
health maintenance organization shall pay a penalty in the amount
of the lesser of:
(1) 100 percent of the difference between the billed
charges, as submitted on the claim, and the contracted rate; or
(2) $10,000 [$200,000].
(d) Except as provided by this section, a health maintenance
organization that determines under this subchapter that a claim is
payable, pays only a portion of the amount of the claim on or before
the date the health maintenance organization is required to make a
determination or adjudication of the claim, and pays the balance of
the contracted rate owed for the claim after that date shall pay to
the physician or provider, in addition to the contracted amount
owed, a penalty on the amount not timely paid in the amount of the
lesser of:
(1) 50 percent of the underpaid amount; or
(2) $5,000 [$100,000].
(e) If the balance of the claim is paid on or after the 46th
day and before the 91st day after the date the health maintenance
organization is required to make a determination or adjudication of
the claim, the health maintenance organization shall pay a penalty
on the balance of the claim in the amount of the lesser of:
(1) 100 percent of the underpaid amount; or
(2) $10,000 [$200,000].
SECTION 4. Subchapter J, Chapter 843, Insurance Code, is
amended by adding Section 843.3421 to read as follows:
Sec. 843.3421. PAYMENT APPEAL DEADLINE. If a contract
between a health maintenance organization and a physician or
provider directly or indirectly requires that a contractual dispute
regarding a post-service payment denial or payment dispute be
appealed, the health maintenance organization may not impose a
deadline for filing the appeal that is less than 180 days after the
earlier of:
(1) the date of the initial payment or denial notice;
or
(2) the latest date for making a payment or
notification with respect to the claim under this subchapter.
SECTION 5. Subchapter J, Chapter 843, Insurance Code, is
amended by adding Section 843.355 to read as follows:
Sec. 843.355. PAYMENT FOR IMMUNIZATIONS, VACCINES, AND
SERUMS. (a) A contract between a health maintenance organization
and a physician or provider must disclose the source of the
information used to calculate a fee payment for an immunization,
vaccine, or serum. The information must be made readily accessible
to the physician or provider, and the contract must include an
explanation of how the physician or provider may access the
information.
(b) Notwithstanding Section 843.321(a)(3), a health
maintenance organization is not required to notify a physician or
provider, and a contract between a health maintenance organization
and a physician or provider may not directly or indirectly require
the health maintenance organization to notify the physician or
provider, before a change in a fee payment described by Subsection
(a) takes effect if the payment change results from a change in
information described by Subsection (a), the source of which is a
third party not controlled by the health maintenance organization,
such as the Centers for Disease Control Vaccine Price List.
(c) A contract between a health maintenance organization
and a physician or provider must require the health maintenance
organization to provide notice of a change of a source of
information described by Subsection (a) used to calculate the fee
payment for an immunization, vaccine, or serum not later than the
90th day before the date the change of source takes effect.
SECTION 6. Section 1301.102(c), Insurance Code, is amended
to read as follows:
(c) An insurer shall accept as proof of timely filing of a
claim for medical care or health care services:
(1) a claim filed in compliance with Subsection (b);
or
(2) information from any [another] insurer authorized
or eligible to engage in the business of insurance in this state or
health maintenance organization showing that the physician or
health care provider submitted the claim for medical care or health
care services to the insurer or health maintenance organization in
compliance with Subsection (b).
SECTION 7. Sections 1301.137(a), (b), (d), and (e),
Insurance Code, are amended to read as follows:
(a) Except as provided by this section, if a clean claim
submitted to an insurer is payable and the insurer does not
determine under Subchapter C that the claim is payable and pay the
claim on or before the date the insurer is required to make a
determination or adjudication of the claim, the insurer shall pay
the preferred provider making the claim the contracted rate owed on
the claim plus a penalty in the amount of the lesser of:
(1) 50 percent of the difference between the billed
charges, as submitted on the claim, and the contracted rate; or
(2) $5,000 [$100,000].
(b) If the claim is paid on or after the 46th day and before
the 91st day after the date the insurer is required to make a
determination or adjudication of the claim, the insurer shall pay a
penalty in the amount of the lesser of:
(1) 100 percent of the difference between the billed
charges, as submitted on the claim, and the contracted rate; or
(2) $10,000 [$200,000].
(d) Except as provided by this section, an insurer that
determines under Subchapter C that a claim is payable, pays only a
portion of the amount of the claim on or before the date the insurer
is required to make a determination or adjudication of the claim,
and pays the balance of the contracted rate owed for the claim after
that date shall pay to the preferred provider, in addition to the
contracted amount owed, a penalty on the amount not timely paid in
the amount of the lesser of:
(1) 50 percent of the underpaid amount; or
(2) $5,000 [$100,000].
(e) If the balance of the claim is paid on or after the 46th
day and before the 91st day after the date the insurer is required
to make a determination or adjudication of the claim, the insurer
shall pay a penalty on the balance of the claim in the amount of the
lesser of:
(1) 100 percent of the underpaid amount; or
(2) $10,000 [$200,000].
SECTION 8. Subchapter C-1, Chapter 1301, Insurance Code, is
amended by adding Section 1301.1371 to read as follows:
Sec. 1301.1371. PAYMENT APPEAL DEADLINE. If a contract
between an insurer and a preferred provider directly or indirectly
requires that a contractual dispute regarding a post-service
payment denial or payment dispute be appealed, the insurer may not
impose a deadline for filing the appeal that is less than 180 days
after the earlier of:
(1) the date of the initial payment or denial notice;
or
(2) the latest date for making a payment or
notification with respect to the claim under Subchapter C.
SECTION 9. Subchapter C-1, Chapter 1301, Insurance Code, is
amended by adding Section 1301.140 to read as follows:
Sec. 1301.140. PAYMENT FOR IMMUNIZATIONS, VACCINES, AND
SERUMS. (a) A contract between an insurer and a preferred provider
must disclose the source of the information used to calculate a fee
payment for an immunization, vaccine, or serum. The information
must be made readily accessible to the preferred provider, and the
contract must include an explanation of how the preferred provider
may access the information.
(b) Notwithstanding Section 1301.136(a)(3), an insurer is
not required to notify a preferred provider, and a contract between
an insurer and a preferred provider may not directly or indirectly
require the insurer to notify the preferred provider, before a
change in a fee payment described by Subsection (a) takes effect if
the payment change results from a change in information described
by Subsection (a), the source of which is a third party not
controlled by the insurer, such as the Centers for Disease Control
Vaccine Price List.
(c) A contract between an insurer and a preferred provider
must require the insurer to provide notice of a change of a source
of information described by Subsection (a) used to calculate the
fee payment for an immunization, vaccine, or serum not later than
the 90th day before the date the change takes effect.
SECTION 10. Sections 843.342(m) and 1301.137(l), Insurance
Code, are repealed.
SECTION 11. It is the intent of the legislature that Section
16.013, Civil Practice and Remedies Code, as added by this Act,
applies only to a personal cause of action and does not limit or
modify the jurisdiction and authority of the commissioner of
insurance to enforce the prompt payment requirements of Chapters
843 and 1301, Insurance Code.
SECTION 12. (a) Section 16.013, Civil Practice and
Remedies Code, as added by this Act, applies only to a cause of
action arising from a claim submitted on or after the effective date
of this Act. A cause of action arising from a claim submitted
before the effective date of this Act is governed by the law
applicable to the claim immediately before the effective date of
this Act, and that law is continued in effect for that purpose.
(b) Except as provided by Subsection (c) of this section,
Sections 843.337, 843.342, 1301.102, and 1301.137, Insurance Code,
as amended by this Act, apply only to a claim submitted on or after
the effective date of this Act. A claim submitted before the
effective date of this Act is governed by the law as it existed
immediately before the effective date of this Act, and that law is
continued in effect for that purpose.
(c) With respect to a claim submitted under a contract with
a health maintenance organization or insurer, Sections 843.337,
843.342, 1301.102, and 1301.137, Insurance Code, as amended by this
Act, apply only to a claim submitted under a contract entered into
or renewed on or after the effective date of this Act. A claim
submitted under a contract entered into or renewed before the
effective date of this Act is governed by the law as it existed
immediately before the effective date of this Act, and that law is
continued in effect for that purpose.
(d) Sections 843.3421, 843.355, 1301.1371, and 1301.140,
Insurance Code, as added by this Act, apply only to a contract
entered into or renewed on or after the effective date of this Act.
A contract entered into or renewed before the effective date of this
Act is governed by the law as it existed immediately before the
effective date of this Act, and that law is continued in effect for
that purpose.
SECTION 13. This Act takes effect September 1, 2015.