By: Buckingham S.B. No. 1883
A BILL TO BE ENTITLED
AN ACT
relating to preauthorization and utilization review for certain
health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter J, Chapter 843, Insurance Code is
amended by adding Section 843.3483 to read as follows:
Sec. 843.3483. EXEMPTION FROM PREAUTHORIZATION
REQUIREMENTS. (a) A health maintenance organization that uses a
preauthorization process for health care services may not require a
physician or provider to obtain preauthorization for a particular
health care service if, in the preceding calendar year, the
physician or provider had at least eighty percent of the
physician's or provider's preauthorization requests approved by the
health maintenance organization for that health care service.
(b) Each exemption from preauthorization requirements
described by Subsection (a) shall last for one calendar year and is
only available for a health care service for which the physician or
provider submitted at least five preauthorization requests in the
preceding calendar year.
(c) A health maintenance organization shall notify each
physician or provider who qualifies for an exemption from
preauthorization requirements under Subsection (a) of the
physician's or provider's exempt status, including the health care
services for which the exemption applies and the exemption start
and end date.
(d) If a physician or provider submits a preauthorization
request for a health care service for which an exemption applies
under Subsection (a), the health maintenance organization shall
promptly notify the physician or provider of the applicable
exemption, the calendar year and health care services for which the
exemption applies, and the health maintenance organization payment
requirements under Subsection (e).
(e) If a preauthorization exemption applies to a health care
service under Subsection (a), a health maintenance organization may
not deny or reduce payment to the physician or provider for the
health care service based on medical necessity or appropriateness
of care.
SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code is
amended by adding Section 1301.1354 to read as follows:
Sec. 1301.1354. EXEMPTION FROM PREAUTHORIZATION
REQUIREMENTS. (a) An insurer that uses a preauthorization process
for medical care or health care services may not require a physician
or health care provider to obtain preauthorization for a particular
medical care or health care service if, in the preceding calendar
year, the physician or health care provider had at least eighty
percent of the physician's or health care provider's
preauthorization requests approved by the insurer for that medical
care or health care service.
(b) Each exemption from preauthorization requirements
described by Subsection (a) shall last for one calendar year and is
only available for a medical care or health care service for which
the physician or health care provider submitted at least five
preauthorization requests in the preceding calendar year.
(c) An insurer shall notify each physician or health care
provider who qualifies for an exemption from preauthorization
requirements under Subsection (a) of the physician's or health care
provider's exempt status, including the medical care or health care
services for which the exemption applies and the exemption start
and end date.
(d) If a physician or health care provider submits a
preauthorization request for a medical care or health care service
for which an exemption applies under Subsection (a), the insurer
shall promptly notify the physician or health care provider of the
applicable exemption, the calendar year and medical care or health
care services for which the exemption applies, and the insurer
payment requirements under Subsection (e).
(e) If a preauthorization exemption applies to a medical
care or health care service under Subsection (a), an insurer may not
deny or reduce payment to the physician or health care provider for
the medical care or health care service based on medical necessity
or appropriateness of care.
SECTION 3. Section 4201.206, Insurance Code, is amended to
read as follows:
Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE
ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the
notice requirements of Subchapter G, before an adverse
determination is issued by a utilization review agent who questions
the medical necessity, the appropriateness, or the experimental or
investigational nature of a health care service, the agent shall
provide the health care provider who ordered, requested, provided,
or is to provide the service a reasonable opportunity to discuss
with a physician licensed to practice medicine in this state the
patient's treatment plan and the clinical basis for the agent's
determination.
(b) If the health care service described by Subsection (a)
was ordered, requested, or provided, or is to be provided by a
physician, the opportunity described by that subsection must be
with a physician licensed to practice medicine in this state who is
of the same or similar specialty as that physician.
SECTION 4. The changes in law made by this Act to Section
4201.206, Insurance Code, apply only to utilization review
requested on or after the effective date of this Act. Utilization
review 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 5. This Act takes effect September 1, 2021.