89R5384 SCR-F
By: Hughes S.B. No. 1090
A BILL TO BE ENTITLED
AN ACT
relating to bundling and down-coding practices conducted by certain
providers of dental benefits.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter E, Chapter 1451, Insurance Code, is
amended by adding Section 1451.210 to read as follows:
Sec. 1451.210. LIMITATION ON BUNDLING AND DOWN-CODING. (a)
In this section:
(1) "Bundling" means the practice of combining
distinct medical or dental procedures or components of a more
extensive procedure into one procedure for billing purposes. The
term does not include the denial or adjustment of claims for covered
services in accordance with the patient's dental benefits.
(2) "Down-coding" means the adjustment by a provider
or issuer of an employee benefit plan or health insurance policy of
a submitted claim to reflect a less complex or lower-cost procedure
code. The term does not include the adjustment of payment for
procedures that were improperly or inaccurately billed, or the
denial or adjustment of claims for covered services in accordance
with the patient's dental benefits.
(b) A provider or issuer of an employee benefit plan or
health insurance policy may not change a dentist's submitted
procedure codes through down-coding or bundling unless the provider
or issuer undertakes a professional review of the submitted charges
and supporting clinical information and determines that the
original coding was incorrect, fragmented, or unbundled:
(1) as provided in the current Code on Dental
Procedures and Nomenclature; or
(2) consistent with generally acceptable standards of
care in the practice of dentistry.
SECTION 2. Section 1451.210, Insurance Code, as added by
this Act, applies only to an employee benefit plan for a plan year
that commences on or after January 1, 2026, or a health insurance
policy delivered, issued for delivery, or renewed on or after
January 1, 2026, and any provider network contract entered into on
or after the effective date of this Act in connection with one of
those plans or policies.
SECTION 3. This Act takes effect September 1, 2025.