By: Menéndez, Alvarado S.B. No. 547
Hinojosa of Nueces
A BILL TO BE ENTITLED
AN ACT
relating to notice from a health benefit plan issuer regarding a
physician's or health care provider's preauthorization exemption
status.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 4201.659(e), Insurance Code, is amended
to read as follows:
(e) If a physician or provider submits a preauthorization
request for a health care service for which the physician or
provider qualifies for an exemption from preauthorization
requirements under Section 4201.653, the health maintenance
organization or insurer must promptly provide a notice to the
physician or provider that includes:
(1) a statement that the physician or provider
qualifies for an exemption from preauthorization requirements
under Section 4201.653;
(2) a list of the health care services and health
benefit plans to which the exemption applies;
(3) a statement of the duration of the exemption [the
information described by Subsection (d)]; and
(4) [(2)] a notification of the health maintenance
organization's or insurer's payment requirements.
SECTION 2. Subchapter N, Chapter 4201, Insurance Code, is
amended by adding Section 4201.660 to read as follows:
Sec. 4201.660. EXEMPTION STATUS NOTIFICATION TO
DEPARTMENT; DATABASE AND REPORT. (a) A health maintenance
organization or insurer that uses a preauthorization process for
health care services shall provide written notice to the department
of a physician's or provider's preauthorization exemption status
under this subchapter not later than the 10th day after the date on
which the health maintenance organization or insurer:
(1) completes an evaluation of the physician or
provider as required by Section 4201.653(b) and determines whether
the physician or provider qualifies for an exemption;
(2) determines that the health maintenance
organization or insurer will continue the physician's or provider's
exemption under Section 4201.653(c);
(3) provides notice to the physician or provider of a
determination to rescind the physician's or provider's exemption;
or
(4) makes an internal appeal determination or receives
a determination from an independent review organization under
Section 4201.656 affirming or denying the health maintenance
organization's or insurer's determination to rescind the
physician's or provider's exemption.
(b) The department shall establish and maintain a database
of preauthorization exemption grants, denials, recissions, and
internal appeal and independent review determinations. On the
request of a physician or provider, the department shall provide
the physician or provider with information regarding the
physician's or provider's preauthorization exemption status with
respect to each relevant health maintenance organization or insurer
and with respect to each relevant health care service.
(c) The department shall collect and compile data
regarding:
(1) the number and timing of evaluations being
conducted by each health maintenance organization or insurer under
this subchapter;
(2) the number of internal appeals or independent
reviews conducted by or with respect to each health maintenance
organization or insurer under this subchapter;
(3) the number of exemptions granted, denied, or
rescinded by each health maintenance organization or insurer, by
provider type and health care service; and
(4) the number and outcomes of internal appeals or
independent reviews conducted by or with respect to each health
maintenance organization or insurer.
(d) The department shall annually prepare a statistical
report reflecting the data collected under Subsection (c) and make
the report available to the public on request.
SECTION 3. Section 4201.659(d), Insurance Code, is
repealed.
SECTION 4. Subchapter N, Chapter 4201, Insurance Code, as
amended by this Act, applies only to a determination regarding a
physician's or provider's preauthorization exemption status made on
or after the effective date of this Act. A determination made
before the effective date of this Act 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 5. This Act takes effect September 1, 2025.