85R7231 SCL-D
By: Workman H.B. No. 2345
A BILL TO BE ENTITLED
AN ACT
relating to the performance and appeal of utilization review by and
under the direction of physicians.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 4201.152, Insurance Code, is amended to
read as follows:
Sec. 4201.152. UTILIZATION REVIEW UNDER DIRECTION OF
PHYSICIAN. A utilization review agent shall conduct utilization
review under the direction of a physician licensed to practice
medicine in this [by a] state [licensing agency in the United
States].
SECTION 2. Subchapter D, Chapter 4201, Insurance Code, is
amended by adding Section 4201.1525 to read as follows:
Sec. 4201.1525. UTILIZATION REVIEW BY PHYSICIANS. (a) A
utilization review agent that uses a physician to conduct
utilization review may only use a physician licensed to practice
medicine in this state.
(b) A payor that conducts utilization review on the payor's
own behalf is subject to Subsection (a) as if the payor were a
utilization review agent.
SECTION 3. Section 4201.356, Insurance Code, is amended to
read as follows:
Sec. 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY
REVIEW. (a) The procedures for appealing an adverse determination
must provide that a physician licensed to practice medicine in this
state makes the decision on the appeal, except as provided by
Subsection (b).
(b) If not later than the 10th working day after the date an
appeal is denied the enrollee's health care provider states in
writing good cause for having a particular type of specialty
provider review the case, a health care provider licensed in this
state who is of the same or a similar specialty as the health care
provider who would typically manage the medical or dental
condition, procedure, or treatment under consideration for review
shall review the decision denying the appeal. The specialty review
must be completed within 15 working days of the date the health care
provider's request for specialty review is received.
SECTION 4. Section 4201.357(a), Insurance Code, is amended
to read as follows:
(a) The procedures for appealing an adverse determination
must include, in addition to the written appeal, a procedure for an
expedited appeal of a denial of emergency care or a denial of
continued hospitalization. That procedure must include a review
by a health care provider who:
(1) has not previously reviewed the case; [and]
(2) is of the same or a similar specialty as the health
care provider who would typically manage the medical or dental
condition, procedure, or treatment under review in the appeal; and
(3) is licensed in this state.
SECTION 5. Section 4201.454, Insurance Code, is amended to
read as follows:
Sec. 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF
PROVIDER OF SAME SPECIALTY. A specialty utilization review agent
shall conduct utilization review under the direction of a health
care provider who is of the same specialty as the agent and who is
licensed or otherwise authorized to provide the specialty health
care service in this [by a] state [licensing agency in the United
States].
SECTION 6. Section 1305.351(d), Insurance Code, is amended
to read as follows:
(d) A [Notwithstanding Section 4201.152, a] utilization
review agent or an insurance carrier that uses doctors to perform
reviews of health care services provided under this chapter,
including utilization review, or peer reviews under Section
408.0231(g), Labor Code, may only use doctors licensed to practice
in this state.
SECTION 7. Section 408.023(h), Labor Code, is amended to
read as follows:
(h) A [Notwithstanding Section 4201.152, Insurance Code, a]
utilization review agent or an insurance carrier that uses doctors
to perform reviews of health care services provided under this
subtitle, including utilization review, may only use doctors
licensed to practice in this state.
SECTION 8. The change in law made by this Act applies only
to utilization review that was requested on or after the effective
date of this Act. Utilization review that was requested 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 9. This Act takes effect September 1, 2017.