| 1 | 1 | | 89R2727 RDS-F |
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| 2 | 2 | | By: Menéndez S.B. No. 177 |
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| 3 | 3 | | |
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| 4 | 4 | | |
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| 5 | 5 | | |
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| 6 | 6 | | |
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| 7 | 7 | | A BILL TO BE ENTITLED |
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| 8 | 8 | | AN ACT |
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| 9 | 9 | | relating to telephone access for certain health benefit plan |
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| 10 | 10 | | verifications and preauthorization requests and for utilization |
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| 11 | 11 | | review requests. |
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| 12 | 12 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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| 13 | 13 | | SECTION 1. Section 843.347(c), Insurance Code, is amended |
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| 14 | 14 | | to read as follows: |
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| 15 | 15 | | (c) A health maintenance organization shall have |
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| 16 | 16 | | appropriate personnel reasonably available at a toll-free |
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| 17 | 17 | | telephone number to provide a verification under this section 24 |
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| 18 | 18 | | hours a day, seven days a week, including [between 6 a.m. and 6 p.m. |
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| 19 | 19 | | central time Monday through Friday on each day that is not a legal |
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| 20 | 20 | | holiday and between 9 a.m. and noon central time on Saturday, |
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| 21 | 21 | | Sunday, and] legal holidays. A health maintenance organization |
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| 22 | 22 | | must: |
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| 23 | 23 | | (1) have a telephone system capable of accepting or |
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| 24 | 24 | | recording incoming phone calls for verifications during any period |
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| 25 | 25 | | in which personnel are not available due to circumstances beyond |
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| 26 | 26 | | the health maintenance organization's reasonable control; [after 6 |
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| 27 | 27 | | p.m. central time Monday through Friday and after noon central time |
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| 28 | 28 | | on Saturday, Sunday, and legal holidays] and |
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| 29 | 29 | | (2) respond [responding] to each of those calls as |
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| 30 | 30 | | soon as possible but not later than two hours after [on or before |
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| 31 | 31 | | the second calendar day after the date] the call is received. |
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| 32 | 32 | | SECTION 2. Section 843.348(f), Insurance Code, is amended |
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| 33 | 33 | | to read as follows: |
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| 34 | 34 | | (f) A health maintenance organization shall have |
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| 35 | 35 | | appropriate personnel reasonably available at a toll-free |
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| 36 | 36 | | telephone number to respond to requests for a preauthorization 24 |
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| 37 | 37 | | hours a day, seven days a week, including [between 6 a.m. and 6 p.m. |
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| 38 | 38 | | central time Monday through Friday on each day that is not a legal |
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| 39 | 39 | | holiday and between 9 a.m. and noon central time on Saturday, |
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| 40 | 40 | | Sunday, and] legal holidays. A health maintenance organization |
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| 41 | 41 | | must: |
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| 42 | 42 | | (1) have a telephone system capable of accepting or |
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| 43 | 43 | | recording incoming phone calls for preauthorizations during any |
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| 44 | 44 | | period in which personnel are not available due to circumstances |
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| 45 | 45 | | beyond the health maintenance organization's reasonable control; |
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| 46 | 46 | | [after 6 p.m. central time Monday through Friday and after noon |
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| 47 | 47 | | central time on Saturday, Sunday, and legal holidays] and |
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| 48 | 48 | | (2) respond [responding] to each of those calls as |
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| 49 | 49 | | soon as possible but not later than two [24] hours after the call is |
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| 50 | 50 | | received. |
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| 51 | 51 | | SECTION 3. Section 1301.133(c), Insurance Code, is amended |
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| 52 | 52 | | to read as follows: |
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| 53 | 53 | | (c) An insurer shall have appropriate personnel reasonably |
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| 54 | 54 | | available at a toll-free telephone number to provide a verification |
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| 55 | 55 | | under this section 24 hours a day, seven days a week, including |
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| 56 | 56 | | [between 6 a.m. and 6 p.m. central time Monday through Friday on |
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| 57 | 57 | | each day that is not a legal holiday and between 9 a.m. and noon |
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| 58 | 58 | | central time on Saturday, Sunday, and] legal holidays. An insurer |
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| 59 | 59 | | must: |
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| 60 | 60 | | (1) have a telephone system capable of accepting or |
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| 61 | 61 | | recording incoming phone calls for verifications during any period |
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| 62 | 62 | | in which personnel are not available due to circumstances beyond |
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| 63 | 63 | | the insurer's reasonable control; [after 6 p.m. central time Monday |
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| 64 | 64 | | through Friday and after noon central time on Saturday, Sunday, and |
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| 65 | 65 | | legal holidays] and |
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| 66 | 66 | | (2) respond [responding] to each of those calls as |
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| 67 | 67 | | soon as possible but not later than two hours after [on or before |
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| 68 | 68 | | the second calendar day after the date] the call is received. |
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| 69 | 69 | | SECTION 4. Section 1301.135(e), Insurance Code, is amended |
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| 70 | 70 | | to read as follows: |
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| 71 | 71 | | (e) An insurer shall have appropriate personnel reasonably |
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| 72 | 72 | | available at a toll-free telephone number to respond to requests |
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| 73 | 73 | | for a preauthorization 24 hours a day, seven days a week, including |
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| 74 | 74 | | [between 6 a.m. and 6 p.m. central time Monday through Friday on |
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| 75 | 75 | | each day that is not a legal holiday and between 9 a.m. and noon |
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| 76 | 76 | | central time on Saturday, Sunday, and] legal holidays. An insurer |
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| 77 | 77 | | must: |
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| 78 | 78 | | (1) have a telephone system capable of accepting or |
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| 79 | 79 | | recording incoming phone calls for preauthorizations during any |
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| 80 | 80 | | period in which personnel are not available due to circumstances |
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| 81 | 81 | | beyond the insurer's reasonable control; [after 6 p.m. central time |
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| 82 | 82 | | Monday through Friday and after noon central time on Saturday, |
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| 83 | 83 | | Sunday, and legal holidays] and |
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| 84 | 84 | | (2) respond [responding] to each of those calls as |
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| 85 | 85 | | soon as possible but not later than two [24] hours after the call is |
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| 86 | 86 | | received. |
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| 87 | 87 | | SECTION 5. Section 4201.004(a), Insurance Code, is amended |
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| 88 | 88 | | to read as follows: |
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| 89 | 89 | | (a) A utilization review agent shall: |
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| 90 | 90 | | (1) have appropriate personnel reasonably available, |
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| 91 | 91 | | by toll-free telephone 24 hours a day, seven days a week, including |
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| 92 | 92 | | legal holidays [at least 40 hours per week during normal business |
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| 93 | 93 | | hours in this state], to discuss patients' care and allow response |
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| 94 | 94 | | to telephone review requests; |
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| 95 | 95 | | (2) have a telephone system capable, during any period |
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| 96 | 96 | | in which personnel are not available due to circumstances beyond |
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| 97 | 97 | | the utilization review agent's reasonable control [hours other than |
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| 98 | 98 | | normal business hours], of accepting or recording incoming |
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| 99 | 99 | | telephone calls or of providing instructions to a caller; and |
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| 100 | 100 | | (3) respond to a call made during a period described by |
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| 101 | 101 | | Subdivision (2) as soon as possible but [hours other than normal |
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| 102 | 102 | | business hours] not later than two hours [the second working day] |
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| 103 | 103 | | after the call is received [later of: |
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| 104 | 104 | | [(A) the date the call was received; or |
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| 105 | 105 | | [(B) the date the details necessary to respond |
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| 106 | 106 | | have been received from the caller]. |
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| 107 | 107 | | SECTION 6. This Act takes effect September 1, 2025. |
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