Texas 2017 - 85th Regular

Texas House Bill HB2345 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New	Differences
1	1	85R7231 SCL-D
2	2	By: Workman H.B. No. 2345
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the performance and appeal of utilization review by and
8	8	under the direction of physicians.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 4201.152, Insurance Code, is amended to
11	11	read as follows:
12	12	Sec. 4201.152. UTILIZATION REVIEW UNDER DIRECTION OF
13	13	PHYSICIAN. A utilization review agent shall conduct utilization
14	14	review under the direction of a physician licensed to practice
15	15	medicine in this [by a] state [licensing agency in the United
16	16	States].
17	17	SECTION 2. Subchapter D, Chapter 4201, Insurance Code, is
18	18	amended by adding Section 4201.1525 to read as follows:
19	19	Sec. 4201.1525. UTILIZATION REVIEW BY PHYSICIANS. (a) A
20	20	utilization review agent that uses a physician to conduct
21	21	utilization review may only use a physician licensed to practice
22	22	medicine in this state.
23	23	(b) A payor that conducts utilization review on the payor's
24	24	own behalf is subject to Subsection (a) as if the payor were a
25	25	utilization review agent.
26	26	SECTION 3. Section 4201.356, Insurance Code, is amended to
27	27	read as follows:
28	28	Sec. 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY
29	29	REVIEW. (a) The procedures for appealing an adverse determination
30	30	must provide that a physician licensed to practice medicine in this
31	31	state makes the decision on the appeal, except as provided by
32	32	Subsection (b).
33	33	(b) If not later than the 10th working day after the date an
34	34	appeal is denied the enrollee's health care provider states in
35	35	writing good cause for having a particular type of specialty
36	36	provider review the case, a health care provider licensed in this
37	37	state who is of the same or a similar specialty as the health care
38	38	provider who would typically manage the medical or dental
39	39	condition, procedure, or treatment under consideration for review
40	40	shall review the decision denying the appeal. The specialty review
41	41	must be completed within 15 working days of the date the health care
42	42	provider's request for specialty review is received.
43	43	SECTION 4. Section 4201.357(a), Insurance Code, is amended
44	44	to read as follows:
45	45	(a) The procedures for appealing an adverse determination
46	46	must include, in addition to the written appeal, a procedure for an
47	47	expedited appeal of a denial of emergency care or a denial of
48	48	continued hospitalization. That procedure must include a review
49	49	by a health care provider who:
50	50	(1) has not previously reviewed the case; [and]
51	51	(2) is of the same or a similar specialty as the health
52	52	care provider who would typically manage the medical or dental
53	53	condition, procedure, or treatment under review in the appeal; and
54	54	(3) is licensed in this state.
55	55	SECTION 5. Section 4201.454, Insurance Code, is amended to
56	56	read as follows:
57	57	Sec. 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF
58	58	PROVIDER OF SAME SPECIALTY. A specialty utilization review agent
59	59	shall conduct utilization review under the direction of a health
60	60	care provider who is of the same specialty as the agent and who is
61	61	licensed or otherwise authorized to provide the specialty health
62	62	care service in this [by a] state [licensing agency in the United
63	63	States].
64	64	SECTION 6. Section 1305.351(d), Insurance Code, is amended
65	65	to read as follows:
66	66	(d) A [Notwithstanding Section 4201.152, a] utilization
67	67	review agent or an insurance carrier that uses doctors to perform
68	68	reviews of health care services provided under this chapter,
69	69	including utilization review, or peer reviews under Section
70	70	408.0231(g), Labor Code, may only use doctors licensed to practice
71	71	in this state.
72	72	SECTION 7. Section 408.023(h), Labor Code, is amended to
73	73	read as follows:
74	74	(h) A [Notwithstanding Section 4201.152, Insurance Code, a]
75	75	utilization review agent or an insurance carrier that uses doctors
76	76	to perform reviews of health care services provided under this
77	77	subtitle, including utilization review, may only use doctors
78	78	licensed to practice in this state.
79	79	SECTION 8. The change in law made by this Act applies only
80	80	to utilization review that was requested on or after the effective
81	81	date of this Act. Utilization review that was requested before the
82	82	effective date of this Act is governed by the law as it existed
83	83	immediately before the effective date of this Act, and that law is
84	84	continued in effect for that purpose.
85	85	SECTION 9. This Act takes effect September 1, 2017.