86R10759 LED-D
By: Davis of Harris H.B. No. 3478
A BILL TO BE ENTITLED
AN ACT
relating to an independent medical review of certain determinations
by the Health and Human Services Commission or a Medicaid managed
care organization.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.00715 to read as follows:
Sec. 533.00715. INDEPENDENT APPEALS PROCEDURE. (a) In
this section, "third-party arbiter" means a third-party medical
review organization that provides objective, unbiased medical
necessity determinations conducted by clinical staff with
education and practice in the same or similar practice area as the
procedure for which an independent determination of medical
necessity is sought.
(b) The commission shall contract with at least three
independent, third-party arbiters to resolve recipient appeals of
any commission or a Medicaid managed care organization adverse
benefit determination or reduction in or denial of health care
services on the basis of medical necessity.
(c) The commission shall establish a common procedure for
appeals. The procedure must provide that a health care service
ordered by a health care provider is presumed medically necessary
and the commission or Medicaid managed care organization bears the
burden of proof to show the health care service is not medically
necessary. The commission shall also establish a procedure for
expedited appeals that allows a third-party arbiter to:
(1) identify an appeal that requires an expedited
resolution; and
(2) resolve the appeal within a specified period.
(d) Subject to Subsection (e), the commission shall ensure
an appeal is randomly assigned to a third-party arbiter.
(e) The commission shall ensure each third-party arbiter
has the necessary medical expertise to resolve an appeal.
(f) A third-party arbiter shall establish and maintain an
Internet portal through which a recipient may track the status and
final disposition of an appeal.
(g) A third-party arbiter shall educate recipients and
employees of Medicaid managed care organizations regarding appeals
processes, options, and proper and improper denials of health care
services on the basis of medical necessity.
(h) A third-party arbiter shall review aggregate denial
data categorized by Medicaid managed care plan to identify trends
and determine whether a Medicaid managed care organization is
disproportionately denying prior authorization requests from a
single provider or set of providers.
SECTION 2. As soon as practicable after the effective date
of this Act, the executive commissioner of the Health and Human
Services Commission shall adopt the rules necessary to implement
this Act.
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.