Texas 2025 - 89th Regular

Texas House Bill HB3863 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	89R6276 SCF-F
2	2	By: Canales H.B. No. 3863
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5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to claims payments to health care providers by health
10	10	maintenance organizations, preferred provider benefit plans, or
11	11	managed care organizations.
12	12	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	13	SECTION 1. Section 540.0265, Government Code, as effective
14	14	April 1, 2025, is amended to read as follows:
15	15	Sec. 540.0265. PROMPT PAYMENT OF CLAIMS. (a) A contract to
16	16	which this subchapter applies must require the contracting Medicaid
17	17	managed care organization to pay a physician or provider for health
18	18	care services provided to a recipient under a Medicaid managed care
19	19	plan on any claim for payment the organization receives with
20	20	documentation reasonably necessary for the organization to process
21	21	the claim[:
22	22	[(1)] not later than:
23	23	(1) [(A)] the 10th day after the date the organization
24	24	receives the claim if the claim relates to services a nursing
25	25	facility, intermediate care facility, or group home provided; and
26	26	(2) [(B)] the 30th day after the date the organization
27	27	receives the claim if the claim [relates to the provision of
28	28	long-term services and supports not subject to Paragraph (A); and
29	29	[(C) the 45th day after the date the organization
30	30	receives the claim if the claim] is not subject to Subdivision (1)
31	31	[Paragraph (A) or (B); or
32	32	[(2) within a period, not to exceed 60 days, specified
33	33	by a written agreement between the physician or provider and the
34	34	organization].
35	35	(b) A contract to which this subchapter applies must require
36	36	the contracting Medicaid managed care organization to demonstrate
37	37	to the commission that the organization pays claims relating to the
38	38	provision of long-term services and supports other than those
39	39	described by Subsection (a)(1) [described by Subsection (a)(1)(B)]
40	40	on average not later than the 21st day after the date the
41	41	organization receives the claim.
42	42	(c) A contract to which this subchapter applies must
43	43	prohibit the contracting Medicaid managed care organization from
44	44	requiring a physician or provider to accept a claim payment in the
45	45	form of a virtual credit card or any other payment method with
46	46	respect to which a fee, including a processing fee, administrative
47	47	fee, percentage amount, or dollar amount, is assessed to receive
48	48	the payment. A nominal fee assessed by the physician's or provider's
49	49	bank to receive an electronic funds transfer is not considered to be
50	50	a prohibited fee for purposes of this subsection.
51	51	SECTION 2. Section 540.0267(a), Government Code, as
52	52	effective April 1, 2025, is amended to read as follows:
53	53	(a) A contract to which this subchapter applies must require
54	54	the contracting Medicaid managed care organization to develop,
55	55	implement, and maintain a system for tracking and resolving
56	56	provider appeals related to claims payment. The system must
57	57	include a process that requires:
58	58	(1) a tracking mechanism to document the status and
59	59	final disposition of each provider's claims payment appeal;
60	60	(2) contracting with physicians who are not network
61	61	providers and who are of the same or related specialty as the
62	62	appealing physician to resolve claims disputes that:
63	63	(A) relate to denial on the basis of medical
64	64	necessity; and
65	65	(B) remain unresolved after a provider appeal;
66	66	(3) the determination of the physician resolving the
67	67	dispute to be binding on the organization and provider; and
68	68	(4) the organization to allow a provider to initiate
69	69	an appeal of a claim that relates to the provision of long-term
70	70	services and supports other than those described by Section
71	71	540.0265(a)(1) and that has not been paid before the time
72	72	prescribed by Section 540.0265(a)(2) [540.0265(a)(1)(B)].
73	73	SECTION 3. Section 843.338, Insurance Code, is amended to
74	74	read as follows:
75	75	Sec. 843.338. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except
76	76	as provided by Sections 843.3385 and 843.339, not later than the
77	77	[45th day after the date on which a health maintenance organization
78	78	receives a clean claim from a participating physician or provider
79	79	in a nonelectronic format or the] 30th day after the date the health
80	80	maintenance organization receives a clean claim from a
81	81	participating physician or provider [that is electronically
82	82	submitted], the health maintenance organization shall make a
83	83	determination of whether the claim is payable and:
84	84	(1) if the health maintenance organization determines
85	85	the entire claim is payable, pay the total amount of the claim in
86	86	accordance with the contract between the physician or provider and
87	87	the health maintenance organization;
88	88	(2) if the health maintenance organization determines
89	89	a portion of the claim is payable, pay the portion of the claim that
90	90	is not in dispute and notify the physician or provider in writing
91	91	why the remaining portion of the claim will not be paid; or
92	92	(3) if the health maintenance organization determines
93	93	that the claim is not payable, notify the physician or provider in
94	94	writing why the claim will not be paid.
95	95	SECTION 4. Section 843.340(a), Insurance Code, is amended
96	96	to read as follows:
97	97	(a) Except as provided by Section 843.3385, if a health
98	98	maintenance organization intends to audit a claim submitted by a
99	99	participating physician or provider, the health maintenance
100	100	organization shall pay the charges submitted at 100 percent of the
101	101	contracted rate on the claim not later than the 30th day after the
102	102	date the health maintenance organization receives the clean claim
103	103	from the participating physician or provider [if submitted
104	104	electronically or if submitted nonelectronically not later than the
105	105	45th day after the date on which the health maintenance
106	106	organization receives the clean claim from a participating
107	107	physician or provider]. The health maintenance organization shall
108	108	clearly indicate on the explanation of payment statement in the
109	109	manner prescribed by the commissioner by rule that the clean claim
110	110	is being paid at 100 percent of the contracted rate, subject to
111	111	completion of the audit.
112	112	SECTION 5. Sections 843.342(b) and (e), Insurance Code, are
113	113	amended to read as follows:
114	114	(b) If the claim is paid on or after the 31st [46th] day and
115	115	before the 91st day after the date the health maintenance
116	116	organization is required to make a determination or adjudication of
117	117	the claim, the health maintenance organization shall pay a penalty
118	118	in the amount of the lesser of:
119	119	(1) 100 percent of the difference between the billed
120	120	charges, as submitted on the claim, and the contracted rate; or
121	121	(2) $200,000.
122	122	(e) If the balance of the claim is paid on or after the 31st
123	123	[46th] day and before the 91st day after the date the health
124	124	maintenance organization is required to make a determination or
125	125	adjudication of the claim, the health maintenance organization
126	126	shall pay a penalty on the balance of the claim in the amount of the
127	127	lesser of:
128	128	(1) 100 percent of the underpaid amount; or
129	129	(2) $200,000.
130	130	SECTION 6. Section 843.346, Insurance Code, is amended to
131	131	read as follows:
132	132	Sec. 843.346. PAYMENT OF CLAIMS. (a) Except as provided by
133	133	this subchapter, a health maintenance organization shall pay a
134	134	physician or provider for health care services and benefits
135	135	provided to an enrollee not later than[:
136	136	[(1)] the 30th [45th] day after the date on which a
137	137	claim for payment is received with the documentation reasonably
138	138	necessary to process the claim[; or
139	139	[(2) if applicable, within the number of calendar days
140	140	specified by written agreement between the physician or provider
141	141	and the health maintenance organization].
142	142	(b) A health maintenance organization may not require a
143	143	physician or provider to accept a claim payment in the form of a
144	144	virtual credit card or any other payment method with respect to
145	145	which a fee, including a processing fee, administrative fee,
146	146	percentage amount, or dollar amount, is assessed to receive the
147	147	payment. A nominal fee assessed by the physician's or provider's
148	148	bank to receive an electronic funds transfer is not considered to be
149	149	a prohibited fee for purposes of this subsection.
150	150	SECTION 7. Section 1301.0053(a), Insurance Code, is amended
151	151	to read as follows:
152	152	(a) If an out-of-network provider provides emergency care
153	153	as defined by Section 1301.155 or post-emergency stabilization care
154	154	to an enrollee in an exclusive provider benefit plan, the issuer of
155	155	the plan shall reimburse the out-of-network provider at the usual
156	156	and customary rate or at a rate agreed to by the issuer and the
157	157	out-of-network provider for the provision of the services and any
158	158	supply related to those services. The insurer shall make a payment
159	159	required by this subsection directly to the provider not later
160	160	than[, as applicable:
161	161	[(1)] the 30th day after the date the insurer receives
162	162	a [an electronic] clean claim as defined by Section 1301.101 for
163	163	those services that includes all information necessary for the
164	164	insurer to pay the claim[; or
165	165	[(2) the 45th day after the date the insurer receives a
166	166	nonelectronic clean claim as defined by Section 1301.101 for those
167	167	services that includes all information necessary for the insurer to
168	168	pay the claim].
169	169	SECTION 8. Section 1301.064, Insurance Code, is amended to
170	170	read as follows:
171	171	Sec. 1301.064. CONTRACT PROVISIONS RELATING TO PAYMENT OF
172	172	CLAIMS. Subject to Subchapter C, a preferred provider contract
173	173	must provide for payment to a physician or health care provider for
174	174	health care services and benefits provided to an insured under the
175	175	contract and to which the insured is entitled under the terms of the
176	176	contract not later than[:
177	177	[(1)] the 30th [45th] day after the date on which a
178	178	claim for payment is received with the documentation reasonably
179	179	necessary to process the claim[; or
180	180	[(2) if applicable, within the number of calendar days
181	181	specified by written agreement between the physician or health care
182	182	provider and the insurer].
183	183	SECTION 9. Section 1301.103, Insurance Code, is amended to
184	184	read as follows:
185	185	Sec. 1301.103. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except
186	186	as provided by Sections 1301.104 and 1301.1054, not later than the
187	187	[45th day after the date an insurer receives a clean claim from a
188	188	preferred provider in a nonelectronic format or the] 30th day after
189	189	the date an insurer receives a clean claim from a preferred provider
190	190	[that is electronically submitted], the insurer shall make a
191	191	determination of whether the claim is payable and:
192	192	(1) if the insurer determines the entire claim is
193	193	payable, pay the total amount of the claim in accordance with the
194	194	contract between the preferred provider and the insurer;
195	195	(2) if the insurer determines a portion of the claim is
196	196	payable, pay the portion of the claim that is not in dispute and
197	197	notify the preferred provider in writing why the remaining portion
198	198	of the claim will not be paid; or
199	199	(3) if the insurer determines that the claim is not
200	200	payable, notify the preferred provider in writing why the claim
201	201	will not be paid.
202	202	SECTION 10. Section 1301.105(a), Insurance Code, is amended
203	203	to read as follows:
204	204	(a) Except as provided by Section 1301.1054, an insurer that
205	205	intends to audit a claim submitted by a preferred provider shall pay
206	206	the charges submitted at 100 percent of the contracted rate on the
207	207	claim not later than[:
208	208	[(1)] the 30th day after the date the insurer receives
209	209	the clean claim from the preferred provider [if the claim is
210	210	submitted electronically; or
211	211	[(2) the 45th day after the date the insurer receives
212	212	the clean claim from the preferred provider if the claim is
213	213	submitted nonelectronically].
214	214	SECTION 11. Sections 1301.137(b) and (e), Insurance Code,
215	215	are amended to read as follows:
216	216	(b) If the claim is paid on or after the 31st [46th] day and
217	217	before the 91st day after the date the insurer is required to make a
218	218	determination or adjudication of the claim, the insurer shall pay a
219	219	penalty in the amount of the lesser of:
220	220	(1) 100 percent of the difference between the billed
221	221	charges, as submitted on the claim, and the contracted rate; or
222	222	(2) $200,000.
223	223	(e) If the balance of the claim is paid on or after the 31st
224	224	[46th] day and before the 91st day after the date the insurer is
225	225	required to make a determination or adjudication of the claim, the
226	226	insurer shall pay a penalty on the balance of the claim in the
227	227	amount of the lesser of:
228	228	(1) 100 percent of the underpaid amount; or
229	229	(2) $200,000.
230	230	SECTION 12. Subchapter C-1, Chapter 1301, Insurance Code,
231	231	is amended by adding Section 1301.141 to read as follows:
232	232	Sec. 1301.141. FORM OF CLAIM PAYMENTS. An insurer may not
233	233	require a physician or health care provider to accept a claim
234	234	payment in the form of a virtual credit card or any other payment
235	235	method with respect to which a fee, including a processing fee,
236	236	administrative fee, percentage amount, or dollar amount, is
237	237	assessed to receive the payment. A nominal fee assessed by the
238	238	physician's or provider's bank to receive an electronic funds
239	239	transfer is not considered to be a prohibited fee for purposes of
240	240	this subsection.
241	241	SECTION 13. Section 1301.155(c), Insurance Code, is amended
242	242	to read as follows:
243	243	(c) For emergency care subject to this section or a supply
244	244	related to that care, an insurer shall make a payment required by
245	245	this section directly to the out-of-network provider not later
246	246	than[, as applicable:
247	247	[(1)] the 30th day after the date the insurer receives
248	248	a [an electronic] clean claim as defined by Section 1301.101 for
249	249	those services that includes all information necessary for the
250	250	insurer to pay the claim[; or
251	251	[(2) the 45th day after the date the insurer receives a
252	252	nonelectronic clean claim as defined by Section 1301.101 for those
253	253	services that includes all information necessary for the insurer to
254	254	pay the claim].
255	255	SECTION 14. Section 1301.164(b), Insurance Code, is amended
256	256	to read as follows:
257	257	(b) Except as provided by Subsection (d), an insurer shall
258	258	pay for a covered medical care or health care service performed for
259	259	or a covered supply related to that service provided to an insured
260	260	by an out-of-network provider who is a facility-based provider at
261	261	the usual and customary rate or at an agreed rate if the provider
262	262	performed the service at a health care facility that is a preferred
263	263	provider. The insurer shall make a payment required by this
264	264	subsection directly to the provider not later than[, as applicable:
265	265	[(1)] the 30th day after the date the insurer receives
266	266	a [an electronic] clean claim as defined by Section 1301.101 for
267	267	those services that includes all information necessary for the
268	268	insurer to pay the claim[; or
269	269	[(2) the 45th day after the date the insurer receives a
270	270	nonelectronic clean claim as defined by Section 1301.101 for those
271	271	services that includes all information necessary for the insurer to
272	272	pay the claim].
273	273	SECTION 15. Section 1301.165(b), Insurance Code, is amended
274	274	to read as follows:
275	275	(b) Except as provided by Subsection (d), an insurer shall
276	276	pay for a covered medical care or health care service performed by
277	277	or a covered supply related to that service provided to an insured
278	278	by an out-of-network provider who is a diagnostic imaging provider
279	279	or laboratory service provider at the usual and customary rate or at
280	280	an agreed rate if the provider performed the service in connection
281	281	with a medical care or health care service performed by a preferred
282	282	provider. The insurer shall make a payment required by this
283	283	subsection directly to the provider not later than[, as applicable:
284	284	[(1)] the 30th day after the date the insurer receives a
285	285	[an electronic] clean claim as defined by Section 1301.101 for
286	286	those services that includes all information necessary for the
287	287	insurer to pay the claim[; or
288	288	[(2) the 45th day after the date the insurer receives a
289	289	nonelectronic clean claim as defined by Section 1301.101 for those
290	290	services that includes all information necessary for the insurer to
291	291	pay the claim].
292	292	SECTION 16. Section 1301.166(d), Insurance Code, is amended
293	293	to read as follows:
294	294	(d) The insurer shall make a payment required by this
295	295	section directly to the provider not later than[, as applicable:
296	296	[(1)] the 30th day after the date the insurer receives
297	297	a [an electronic] clean claim as defined by Section 1301.101 for
298	298	those services that includes all information necessary for the
299	299	insurer to pay the claim[; or
300	300	[(2) the 45th day after the date the insurer receives a
301	301	nonelectronic clean claim as defined by Section 1301.101 for those
302	302	services that includes all information necessary for the insurer to
303	303	pay the claim].
304	304	SECTION 17. (a) Sections 540.0265 and 540.0267,
305	305	Government Code, as amended by this Act, apply only to a contract
306	306	entered into on or after the effective date of this Act. A contract
307	307	entered into before the effective date of this Act is governed by
308	308	the law as it existed immediately before the effective date of this
309	309	Act, and that law is continued in effect for that purpose.
310	310	(b) Except as provided by Subsection (c) of this section,
311	311	the changes in law made by this Act to Chapters 843 and 1301,
312	312	Insurance Code, apply only to a claim submitted on or after the
313	313	effective date of this Act. A claim submitted before the effective
314	314	date of this Act is governed by the law as it existed immediately
315	315	before the effective date of this Act, and that law is continued in
316	316	effect for that purpose.
317	317	(c) With respect to a claim submitted under a contract with
318	318	a health maintenance organization or insurer, the changes in law
319	319	made by this Act to Chapters 843 and 1301, Insurance Code, apply
320	320	only to a claim submitted under a contract entered into on or after
321	321	the effective date of this Act. A claim submitted under a contract
322	322	entered into before the effective date of this Act is governed by
323	323	the law as it existed immediately before the effective date of this
324	324	Act, and that law is continued in effect for that purpose.
325	325	SECTION 18. If before implementing any provision of this
326	326	Act a state agency determines that a waiver or authorization from a
327	327	federal agency is necessary for implementation of that provision,
328	328	the agency affected by the provision shall request the waiver or
329	329	authorization and may delay implementing that provision until the
330	330	waiver or authorization is granted.
331	331	SECTION 19. This Act takes effect September 1, 2025.