86R12187 KFF-D
By: Martinez H.B. No. 3212
A BILL TO BE ENTITLED
AN ACT
relating to the procedure for the payment of claims submitted by
certain providers under the Medicaid managed care program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.00553 to read as follows:
Sec. 533.00553. REQUIRED PROCEDURES RELATING TO PROCESSING
CLAIMS BY CERTAIN PROVIDERS. (a) This section applies to a claim
submitted to a managed care organization by a physician or hospital
for the provision of health care services to a recipient receiving
Medicaid benefits under the organization's managed care plan.
(b) A managed care organization may not change the diagnosis
or treatment code or other description of a health care procedure
associated with a claim subject to this section to a code or other
description that will result in a lower reimbursement rate for the
provider unless:
(1) the evaluation of the claim and decision to make
the change is made by a physician employed by the organization for
that purpose; and
(2) the organization informs the provider in detail of
the specific reason for the change.
SECTION 2. Section 533.00553, Government Code, as added by
this Act, applies to a claim for payment submitted to a managed care
organization on or after the effective date of this Act. A claim
for payment submitted before the effective date of this Act is
governed by the law in effect on the date the claim was received,
and the former law is continued in effect for that purpose.
SECTION 3. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 4. This Act takes effect September 1, 2019.