84R5065 SCL-F
By: Bonnen of Galveston H.B. No. 1621
A BILL TO BE ENTITLED
AN ACT
relating to notice and appeal of an adverse determination by
utilization review agents.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 4201.304, Insurance Code, is amended to
read as follows:
Sec. 4201.304. TIME FOR NOTICE OF ADVERSE DETERMINATION.
(a) Subject to Subsection (b), a [A] utilization review agent shall
provide notice of an adverse determination required by this
subchapter as follows:
(1) with respect to a patient who is hospitalized at
the time of the adverse determination, within one working day by
either telephone or electronic transmission to the provider of
record, followed by a letter within three working days notifying
the patient and the provider of record of the adverse
determination;
(2) with respect to a patient who is not hospitalized
at the time of the adverse determination, within three working days
in writing to the provider of record and the patient; or
(3) within the time appropriate to the circumstances
relating to the delivery of the services to the patient and to the
patient's condition, provided that when denying poststabilization
care subsequent to emergency treatment as requested by a treating
physician or other health care provider, the agent shall provide
the notice to the treating physician or other health care provider
not later than one hour after the time of the request.
(b) A utilization review agent shall provide notice of an
adverse determination for a concurrent review of health care
services not later than the 30th day before the date on which the
health care services will be discontinued.
SECTION 2. Subchapter H, Chapter 4201, Insurance Code, is
amended by adding Section 4201.3555 to read as follows:
Sec. 4201.3555. CONTINUATION OF CONCURRENT HEALTH CARE
SERVICES. The procedures for appealing an adverse determination
for a concurrent review of health care services must provide that:
(1) coverage or benefits for the contested health care
services, including prescription drugs, that are the basis of the
adverse determination continues under the enrollee's health
insurance policy or health benefit plan while the appeal is being
considered; and
(2) without regard to whether the adverse
determination is upheld on appeal, the payor may not charge an
enrollee for the cost of the contested health care services,
including prescription drugs, received during the period the appeal
was considered except for an applicable copayment, coinsurance, or
deductible under the enrollee's health insurance policy or health
benefit plan.
SECTION 3. Subchapter I, Chapter 4201, Insurance Code, is
amended by adding Section 4201.404 to read as follows:
Sec. 4201.404. CONTINUATION OF CONCURRENT HEALTH CARE
SERVICES. The procedures for an independent review of an appeal of
an adverse determination for a concurrent review of health care
services must provide that:
(1) coverage or benefits for the contested health care
services, including prescription drugs, that are the basis of the
adverse determination continues under the enrollee's health
insurance policy or health benefit plan while the review is being
considered; and
(2) without regard to whether the adverse
determination is upheld on review, the payor may not charge an
enrollee for the cost of the contested health care services,
including prescription drugs, received during the period the review
was considered except for an applicable copayment, coinsurance, or
deductible under the enrollee's health insurance policy or health
benefit plan.
SECTION 4. This Act applies only to an adverse
determination made in relation to coverage or benefits under a
health insurance policy or health benefit plan delivered, issued
for delivery, or renewed on or after January 1, 2016. An adverse
determination made in relation to coverage or benefits under a
policy or plan delivered, issued for delivery, or renewed before
January 1, 2016, 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 5. This Act takes effect September 1, 2015.