| 1 | 1 | | 86R12187 KFF-D |
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| 2 | 2 | | By: Martinez H.B. No. 3212 |
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| 3 | 3 | | |
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| 4 | 4 | | |
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| 5 | 5 | | A BILL TO BE ENTITLED |
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| 6 | 6 | | AN ACT |
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| 7 | 7 | | relating to the procedure for the payment of claims submitted by |
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| 8 | 8 | | certain providers under the Medicaid managed care program. |
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| 9 | 9 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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| 10 | 10 | | SECTION 1. Subchapter A, Chapter 533, Government Code, is |
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| 11 | 11 | | amended by adding Section 533.00553 to read as follows: |
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| 12 | 12 | | Sec. 533.00553. REQUIRED PROCEDURES RELATING TO PROCESSING |
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| 13 | 13 | | CLAIMS BY CERTAIN PROVIDERS. (a) This section applies to a claim |
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| 14 | 14 | | submitted to a managed care organization by a physician or hospital |
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| 15 | 15 | | for the provision of health care services to a recipient receiving |
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| 16 | 16 | | Medicaid benefits under the organization's managed care plan. |
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| 17 | 17 | | (b) A managed care organization may not change the diagnosis |
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| 18 | 18 | | or treatment code or other description of a health care procedure |
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| 19 | 19 | | associated with a claim subject to this section to a code or other |
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| 20 | 20 | | description that will result in a lower reimbursement rate for the |
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| 21 | 21 | | provider unless: |
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| 22 | 22 | | (1) the evaluation of the claim and decision to make |
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| 23 | 23 | | the change is made by a physician employed by the organization for |
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| 24 | 24 | | that purpose; and |
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| 25 | 25 | | (2) the organization informs the provider in detail of |
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| 26 | 26 | | the specific reason for the change. |
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| 27 | 27 | | SECTION 2. Section 533.00553, Government Code, as added by |
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| 28 | 28 | | this Act, applies to a claim for payment submitted to a managed care |
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| 29 | 29 | | organization on or after the effective date of this Act. A claim |
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| 30 | 30 | | for payment submitted before the effective date of this Act is |
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| 31 | 31 | | governed by the law in effect on the date the claim was received, |
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| 32 | 32 | | and the former law is continued in effect for that purpose. |
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| 33 | 33 | | SECTION 3. If before implementing any provision of this Act |
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| 34 | 34 | | a state agency determines that a waiver or authorization from a |
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| 35 | 35 | | federal agency is necessary for implementation of that provision, |
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| 36 | 36 | | the agency affected by the provision shall request the waiver or |
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| 37 | 37 | | authorization and may delay implementing that provision until the |
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| 38 | 38 | | waiver or authorization is granted. |
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| 39 | 39 | | SECTION 4. This Act takes effect September 1, 2019. |
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