Texas 2025 - 89th Regular

Texas House Bill HB4585 Compare Versions

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

Old	New	Differences
1	1	89R7645 SCF-D
2	2	By: Spiller H.B. No. 4585
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7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to the submission, payment, and audit of certain claims
10	10	for and utilization review of health services, including services
11	11	provided under the Medicaid managed care and child health plan
12	12	programs.
13	13	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
14	14	SECTION 1. The heading to Section 540.0265, Government
15	15	Code, as effective April 1, 2025, is amended to read as follows:
16	16	Sec. 540.0265. SUBMISSION AND [PROMPT] PAYMENT OF CLAIMS.
17	17	SECTION 2. Section 540.0265, Government Code, as effective
18	18	April 1, 2025, is amended by amending Subsection (a) and adding
19	19	Subsections (c), (d), (e), and (f) to read as follows:
20	20	(a) A contract to which this subchapter applies must require
21	21	the contracting Medicaid managed care organization to determine
22	22	whether a claim is payable and pay a physician or provider for
23	23	health care services provided to a recipient under a Medicaid
24	24	managed care plan on any clean claim for payment the organization
25	25	receives [with documentation reasonably necessary for the
26	26	organization to process the claim]:
27	27	(1) not later than:
28	28	(A) the 10th day after the date the organization
29	29	receives the claim if the claim relates to services a nursing
30	30	facility, intermediate care facility, or group home provided;
31	31	(B) the 30th day after the date the organization
32	32	receives the claim if the claim relates to the provision of
33	33	long-term services and supports not subject to Paragraph (A); and
34	34	(C) the 45th day after the date the organization
35	35	receives the claim if the claim is not subject to Paragraph (A) or
36	36	(B); or
37	37	(2) within a period, not to exceed 60 days, specified
38	38	by a written agreement between the physician or provider and the
39	39	organization.
40	40	(c) A contract to which this subchapter applies must require
41	41	a contracting Medicaid managed care organization to disclose to a
42	42	physician or provider:
43	43	(1) the address, including a physical address, where a
44	44	claim is sent for processing;
45	45	(2) the telephone number a physician or provider may
46	46	call regarding a question or concern about a claim;
47	47	(3) the name and physical address of any entity to
48	48	which the organization has delegated claim payment functions;
49	49	(4) the mailing address, physical address, and
50	50	telephone number of any separate claims processing center used to
51	51	process claims for specific services; and
52	52	(5) by providing written notice not later than the
53	53	61st day before the change, any change to an address, telephone
54	54	number, or entity described by Subdivisions (1)-(4).
55	55	(d) A contract to which this subchapter applies must specify
56	56	that the contracting Medicaid managed care organization:
57	57	(1) must allow a physician or provider to submit a
58	58	claim for payment during a period of not less than 95 days beginning
59	59	on the date the service for which the claim is made was provided;
60	60	and
61	61	(2) is subject to the applicable penalties prescribed
62	62	by Section 1301.137, Insurance Code, if the organization fails to
63	63	comply with the payment requirements of this section.
64	64	(e) For purposes of this section:
65	65	(1) a claim a physician or provider submits to a
66	66	Medicaid managed care organization is considered to be a clean
67	67	claim if the claim meets the requirements of Section 1301.131,
68	68	Insurance Code, and rules adopted under that section; and
69	69	(2) the organization is considered to be the insurer
70	70	and the physician or provider is considered to be the preferred
71	71	provider with respect to the application of a provision of Chapter
72	72	1301, Insurance Code, to the organization, physician, or provider.
73	73	(f) The provisions required under this section may not be
74	74	waived, modified, or voided under a contract to which this
75	75	subchapter applies or under a contract between a contracting
76	76	Medicaid managed care organization and a physician or provider,
77	77	except as provided by Subsection (a)(2).
78	78	SECTION 3. Subchapter F, Chapter 540, Government Code, as
79	79	effective April 1, 2025, is amended by adding Section 540.02651 to
80	80	read as follows:
81	81	Sec. 540.02651. AUDIT OF CLAIM; OVERPAYMENT RECOVERY. (a)
82	82	A contract to which this subchapter applies must require the
83	83	contracting Medicaid managed care organization to comply with
84	84	Sections 1301.105(b), (c), and (d), 1301.1051, and 1301.132,
85	85	Insurance Code.
86	86	(b) For purposes of this section, the contracting Medicaid
87	87	managed care organization is considered to be the insurer and the
88	88	physician or provider is considered to be the preferred provider
89	89	with respect to the application of a provision of Chapter 1301,
90	90	Insurance Code, to the organization, physician, or provider.
91	91	(c) The provisions required under this section may not be
92	92	waived, modified, or voided under a contract to which this
93	93	subchapter applies or under a contract between a contracting
94	94	Medicaid managed care organization and a physician or provider.
95	95	SECTION 4. Section 540.0267(a), Government Code, as
96	96	effective April 1, 2025, is amended to read as follows:
97	97	(a) A contract to which this subchapter applies must require
98	98	the contracting Medicaid managed care organization to develop,
99	99	implement, and maintain a system for tracking and resolving
100	100	provider appeals related to claims payment. The system must
101	101	include a process that requires:
102	102	(1) a tracking mechanism to document the status and
103	103	final disposition of each provider's claims payment appeal;
104	104	(2) contracting with physicians who are not network
105	105	providers and who are of the same or related specialty as the
106	106	appealing physician to resolve claims disputes that:
107	107	(A) relate to denial on the basis of medical
108	108	necessity; and
109	109	(B) remain unresolved after a provider appeal;
110	110	(3) contracting with an independent review
111	111	organization overseen by the commission to resolve claims disputes
112	112	in the manner provided by Subchapter I, Chapter 4201, Insurance
113	113	Code, that remain unresolved after an appeal under Subdivision (2),
114	114	if applicable;
115	115	(4) the determination of the independent review
116	116	organization [physician] resolving the dispute to be binding on the
117	117	organization and provider; and
118	118	(5) [(4)] the organization to allow a provider to
119	119	initiate an appeal of a claim that has not been paid before the time
120	120	prescribed by Section 540.0265(a)(1)(B).
121	121	SECTION 5. Subchapter B, Chapter 62, Health and Safety
122	122	Code, is amended by adding Section 62.0551 to read as follows:
123	123	Sec. 62.0551. REQUIRED CONTRACT PROVISIONS. (a) A
124	124	contract between the commission and a child health plan provider
125	125	under Section 62.155 must include the requirements specified by
126	126	Sections 540.0265, 540.02651, and 540.0267, Government Code.
127	127	(b) Sections 540.0265, 540.02651, and 540.0267, Government
128	128	Code, apply to a child health plan provider and health care provider
129	129	providing health care services under the child health plan in the
130	130	same manner and to the same extent those provisions apply to a
131	131	Medicaid managed care organization and a physician or provider
132	132	under the Medicaid program.
133	133	SECTION 6. Section 4201.251, Insurance Code, is amended to
134	134	read as follows:
135	135	Sec. 4201.251. DELEGATION OF UTILIZATION REVIEW. (a) A
136	136	utilization review agent may delegate utilization review to
137	137	qualified personnel in the hospital or other health care facility
138	138	in which the health care services to be reviewed were or are to be
139	139	provided. The delegation does not release the agent from the full
140	140	responsibility for compliance with this chapter or other applicable
141	141	law, including the conduct of those to whom utilization review has
142	142	been delegated.
143	143	(b) A utilization review agent may not delegate utilization
144	144	review to an artificial intelligence application or other similar
145	145	computer software.
146	146	SECTION 7. Section 4201.252(a), Insurance Code, is amended
147	147	to read as follows:
148	148	(a) Personnel employed by or under contract with a
149	149	utilization review agent to perform utilization review:
150	150	(1) must be appropriately trained and qualified and
151	151	meet the requirements of this chapter and other applicable law,
152	152	including applicable licensing requirements; and
153	153	(2) may not delegate utilization review to an
154	154	artificial intelligence application or other similar computer
155	155	software.
156	156	SECTION 8. (a) Sections 540.0265 and 540.0267, Government
157	157	Code, as amended by this Act, and Section 540.02651, Government
158	158	Code, as added by this Act, apply only to a contract between the
159	159	Health and Human Services Commission and a managed care
160	160	organization that is entered into or renewed on or after the
161	161	effective date of this Act.
162	162	(b) To the extent permitted by the terms of the contract,
163	163	the Health and Human Services Commission shall seek to amend a
164	164	contract entered into before the effective date of this Act with a
165	165	managed care organization to comply with Sections 540.0265 and
166	166	540.0267, Government Code, as amended by this Act, and Section
167	167	540.02651, Government Code, as added by this Act.
168	168	SECTION 9. (a) Section 62.0551, Health and Safety Code, as
169	169	added by this Act, applies only to a contract between the Health and
170	170	Human Services Commission and a child health plan provider under
171	171	Chapter 62, Health and Safety Code, that is entered into or renewed
172	172	on or after the effective date of this Act.
173	173	(b) To the extent permitted by the terms of the contract,
174	174	the Health and Human Services Commission shall seek to amend a
175	175	contract entered into before the effective date of this Act with a
176	176	child health plan provider to comply with Section 62.0551, Health
177	177	and Safety Code, as added by this Act.
178	178	SECTION 10. The changes to Chapter 4201, Insurance Code, as
179	179	amended by this Act, apply only to a health benefit plan delivered,
180	180	issued for delivery, or renewed on or after January 1, 2026. A
181	181	health benefit plan delivered, issued for delivery, or renewed
182	182	before January 1, 2026, is governed by the law as it existed
183	183	immediately before the effective date of this Act, and that law is
184	184	continued in effect for that purpose.
185	185	SECTION 11. If before implementing any provision of this
186	186	Act a state agency determines that a waiver or authorization from a
187	187	federal agency is necessary for implementation of that provision,
188	188	the agency affected by the provision shall request the waiver or
189	189	authorization and may delay implementing that provision until the
190	190	waiver or authorization is granted.
191	191	SECTION 12. This Act takes effect September 1, 2025.