88R11672 CJD-D
By: Johnson of Dallas H.B. No. 3773
A BILL TO BE ENTITLED
AN ACT
relating to claims submitted and requests for verification made by
a physician or health care provider to certain health benefit plan
issuers and administrators.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 843.3385, Insurance Code, is amended by
adding Subsection (g) to read as follows:
(g) A health maintenance organization shall accept relevant
clinical records submitted by a treating physician or provider with
a claim related to the records or at any time after submission of
the claim.
SECTION 2. Section 843.342, Insurance Code, is amended by
adding Subsection (o) to read as follows:
(o) For the purposes of calculating a penalty under this
section related to a claim by a physician or provider described by
Section 843.351, the contracted rate for health care services
provided by the physician or provider is the usual and customary
rate for the service in the geographic area in which the service is
provided.
SECTION 3. Section 843.351, Insurance Code, is amended to
read as follows:
Sec. 843.351. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND
PROVIDERS. The provisions of this subchapter relating to prompt
payment by a health maintenance organization of a physician or
provider and to verification of health care services apply to a
physician or provider who:
(1) is not included in the health maintenance
organization delivery network; and
(2) provides health care services to an enrollee[:
[(A) care related to an emergency or its
attendant episode of care as required by state or federal law; or
[(B) specialty or other health care services at
the request of the health maintenance organization or a physician
or provider who is included in the health maintenance organization
delivery network because the services are not reasonably available
within the network].
SECTION 4. Section 1301.069, Insurance Code, is amended to
read as follows:
Sec. 1301.069. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND
HEALTH CARE PROVIDERS. The provisions of this chapter relating to
prompt payment by an insurer of a physician or health care provider
and to verification of medical care or health care services apply to
a physician or provider who:
(1) is not a preferred provider included in the
preferred provider network; and
(2) provides health care services to an insured[:
[(A) care related to an emergency or its
attendant episode of care as required by state or federal law; or
[(B) specialty or other medical care or health
care services at the request of the insurer or a preferred provider
because the services are not reasonably available from a preferred
provider who is included in the preferred delivery network].
SECTION 5. Section 1301.1054, Insurance Code, is amended by
adding Subsection (f) to read as follows:
(f) An insurer shall accept relevant clinical records
submitted by a treating physician or provider with a claim related
to the records or at any time after submission of the claim.
SECTION 6. Section 1301.137, Insurance Code, is amended by
adding Subsection (m) to read as follows:
(m) For the purposes of calculating a penalty under this
section related to a claim by a physician or health care provider
described by Section 1301.069, the contracted rate for health care
services provided by the physician or provider is the usual and
customary rate for the service in the geographic area in which the
service is provided.
SECTION 7. Subchapter E, Chapter 1551, Insurance Code, is
amended by adding Section 1551.231 to read as follows:
Sec. 1551.231. ACCEPTANCE OF CLINICAL RECORDS. The
administrator of a managed care plan provided under the group
benefits program shall accept relevant clinical records submitted
by a treating physician or provider with a claim related to the
records or at any time after submission of the claim.
SECTION 8. Subchapter D, Chapter 1575, Insurance Code, is
amended by adding Section 1575.174 to read as follows:
Sec. 1575.174. ACCEPTANCE OF CLINICAL RECORDS. The
administrator of a managed care plan provided under the group
program shall accept relevant clinical records submitted by a
treating physician or provider with a claim related to the records
or at any time after submission of the claim.
SECTION 9. Subchapter C, Chapter 1579, Insurance Code, is
amended by adding Section 1579.112 to read as follows:
Sec. 1579.112. ACCEPTANCE OF CLINICAL RECORDS. The
administrator of a managed care plan provided under this chapter
shall accept relevant clinical records submitted by a treating
physician or provider with a claim related to the records or at any
time after submission of the claim.
SECTION 10. Subchapter D, Chapter 1601, Insurance Code, is
amended by adding Section 1601.156 to read as follows:
Sec. 1601.156. ACCEPTANCE OF CLINICAL RECORDS. The
administering carrier of a managed care plan provided under this
chapter shall accept relevant clinical records submitted by a
treating physician or provider with a claim related to the records
or at any time after submission of the claim.
SECTION 11. (a) Sections 843.342(o) and 1301.137(m),
Insurance Code, as added by this Act, apply only to a penalty or
interest on a penalty owed with respect to a claim submitted on or
after the effective date of this Act.
(b) Sections 843.351 and 1301.069, Insurance Code, as
amended by this Act, apply only to health care services provided and
verification requests made on or after the effective date of this
Act. Health care services provided and verification requests made
before the effective date of this Act are 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 12. This Act takes effect September 1, 2023.