88R22032 CJD-D
By: Cortez H.B. No. 4367
A BILL TO BE ENTITLED
AN ACT
relating to the preauthorization of medical or health care services
by a health maintenance organization or an insurer.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 843.348, Insurance Code, is amended by
amending Subsection (g) and adding Subsection (g-1) to read as
follows:
(g) Unless a physician or provider has materially
misrepresented the proposed health care services or has
substantially failed to perform the proposed health care services,
if [If] the health maintenance organization has preauthorized
health care services, the health maintenance organization may not
deny or reduce payment to the physician or provider for those
services based on:
(1) medical necessity or appropriateness of care; or
(2) eligibility or coverage determinations if the
proposed health care service is provided to the enrollee before the
31st day after the date the health care service was preauthorized
and coverage is not terminated during that period [unless the
physician or provider has materially misrepresented the proposed
health care services or has substantially failed to perform the
proposed health care services].
(g-1) Notwithstanding Section 843.347 or any other law, and
for the purposes of Subsection (g), a health maintenance
organization may not require that the physician or provider request
verification.
SECTION 2. Section 1301.135, Insurance Code, is amended by
amending Subsection (f) and adding Subsection (f-1) to read as
follows:
(f) Unless a physician or health care provider has
materially misrepresented the proposed medical or health care
services or has substantially failed to perform the proposed
medical or health care services, if [If] an insurer has
preauthorized medical care or health care services, the insurer may
not deny or reduce payment to the physician or [health care]
provider for those services based on:
(1) medical necessity or appropriateness of care; or
(2) eligibility or coverage determinations if the
proposed medical or health care service is provided to the insured
before the 31st day after the date the medical or health care
service was preauthorized and coverage is not terminated during
that period [unless the physician or provider has materially
misrepresented the proposed medical or health care services or has
substantially failed to perform the proposed medical or health care
services].
(f-1) Notwithstanding Section 1301.133 or any other law,
and for the purposes of Subsection (f), an insurer may not require
that the physician or health care provider request verification.
SECTION 3. The changes in law made by this Act apply only to
a request for preauthorization of medical care or health care
services made on or after January 1, 2024, under a health benefit
plan delivered, issued for delivery, or renewed on or after that
date. A request for preauthorization of medical care or health care
services made before January 1, 2024, or on or after January 1,
2024, under a health benefit plan delivered, issued for delivery,
or renewed before that date, 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 4. This Act takes effect September 1, 2023.