84R4909 PMO-F
	By: Taylor of Galveston	S.B. No. 843

	A BILL TO BE ENTITLED
	AN ACT
	relating to prompt payment of health care claims, including payment
	for immunizations, vaccines, and serums.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Subchapter A, Chapter 16, Civil Practice and
	Remedies Code, is amended by adding Section 16.013 to read as
	follows:
	Sec. 16.013.  PROMPT PAYMENT OF HEALTH CARE CLAIMS. A person
	must bring a suit for failure to pay a clean claim in accordance
	with Subchapter J, Chapter 843, or Subchapter C, Chapter 1301,
	Insurance Code, not later than two years after the day the cause of
	action accrues. The cause of action accrues on the latest date
	provided by the applicable subchapter for determining whether the
	claim is payable and making the appropriate payment or
	notification.
	SECTION 2.  Section 843.337(a), Insurance Code, is amended
	to read as follows:
	(a)  A physician or provider must submit a claim for health
	care services to a health maintenance organization not later than
	the 95th day after the date the physician or provider provides the
	health care services for which the claim is made. A health
	maintenance organization shall accept as proof of timely filing:
	(1)  a claim filed in compliance with Subsection (e);
	or
	(2)  information from another health maintenance
	organization or any insurer authorized or eligible to engage in the
	business of insurance in this state showing that the physician or
	provider submitted the claim for health care services to the health
	maintenance organization or insurer in compliance with Subsection
	(e).
	SECTION 3.  Sections 843.342(a), (b), (d), and (e),
	Insurance Code, are amended to read as follows:
	(a)  Except as provided by this section, if a clean claim
	submitted to a health maintenance organization is payable and the
	health maintenance organization does not determine under this
	subchapter that the claim is payable and pay the claim on or before
	the date the health maintenance organization is required to make a
	determination or adjudication of the claim, the health maintenance
	organization shall pay the physician or provider making the claim
	the contracted rate owed on the claim plus a penalty in the amount
	of the lesser of:
	(1)  50 percent of the difference between the billed
	charges, as submitted on the claim, and the contracted rate; or
	(2)  $5,000 [$100,000].
	(b)  If the claim is paid on or after the 46th day and before
	the 91st day after the date the health maintenance organization is
	required to make a determination or adjudication of the claim, the
	health maintenance organization shall pay a penalty in the amount
	of the lesser of:
	(1)  100 percent of the difference between the billed
	charges, as submitted on the claim, and the contracted rate; or
	(2)  $10,000 [$200,000].
	(d)  Except as provided by this section, a health maintenance
	organization that determines under this subchapter that a claim is
	payable, pays only a portion of the amount of the claim on or before
	the date the health maintenance organization is required to make a
	determination or adjudication of the claim, and pays the balance of
	the contracted rate owed for the claim after that date shall pay to
	the physician or provider, in addition to the contracted amount
	owed, a penalty on the amount not timely paid in the amount of the
	lesser of:
	(1)  50 percent of the underpaid amount; or
	(2)  $5,000 [$100,000].
	(e)  If the balance of the claim is paid on or after the 46th
	day and before the 91st day after the date the health maintenance
	organization is required to make a determination or adjudication of
	the claim, the health maintenance organization shall pay a penalty
	on the balance of the claim in the amount of the lesser of:
	(1)  100 percent of the underpaid amount; or
	(2)  $10,000 [$200,000].
	SECTION 4.  Subchapter J, Chapter 843, Insurance Code, is
	amended by adding Section 843.3421 to read as follows:
	Sec. 843.3421.  PAYMENT APPEAL DEADLINE. If a contract
	between a health maintenance organization and a physician or
	provider directly or indirectly requires that a contractual dispute
	regarding a post-service payment denial or payment dispute be
	appealed, the health maintenance organization may not impose a
	deadline for filing the appeal that is less than 180 days after the
	earlier of:
	(1)  the date of the initial payment or denial notice;
	or
	(2)  the latest date for making a payment or
	notification with respect to the claim under this subchapter.
	SECTION 5.  Subchapter J, Chapter 843, Insurance Code, is
	amended by adding Section 843.355 to read as follows:
	Sec. 843.355.  PAYMENT FOR IMMUNIZATIONS, VACCINES, AND
	SERUMS. (a) A contract between a health maintenance organization
	and a physician or provider must disclose the source of the
	information used to calculate a fee payment for an immunization,
	vaccine, or serum. The information must be made readily accessible
	to the physician or provider, and the contract must include an
	explanation of how the physician or provider may access the
	information.
	(b)  Notwithstanding Section 843.321(a)(3), a health
	maintenance organization is not required to notify a physician or
	provider, and a contract between a health maintenance organization
	and a physician or provider may not directly or indirectly require
	the health maintenance organization to notify the physician or
	provider, before a change in a fee payment described by Subsection
	(a) takes effect if the payment change results from a change in
	information described by Subsection (a), the source of which is a
	third party not controlled by the health maintenance organization,
	such as the Centers for Disease Control Vaccine Price List.
	(c)  A contract between a health maintenance organization
	and a physician or provider must require the health maintenance
	organization to provide notice of a change of a source of
	information described by Subsection (a) used to calculate the fee
	payment for an immunization, vaccine, or serum not later than the
	90th day before the date the change of source takes effect.
	SECTION 6.  Section 1301.102(c), Insurance Code, is amended
	to read as follows:
	(c)  An insurer shall accept as proof of timely filing of a
	claim for medical care or health care services:
	(1)  a claim filed in compliance with Subsection (b);
	or
	(2)  information from any [another] insurer authorized
	or eligible to engage in the business of insurance in this state or
	health maintenance organization showing that the physician or
	health care provider submitted the claim for medical care or health
	care services to the insurer or health maintenance organization in
	compliance with Subsection (b).
	SECTION 7.  Sections 1301.137(a), (b), (d), and (e),
	Insurance Code, are amended to read as follows:
	(a)  Except as provided by this section, if a clean claim
	submitted to an insurer is payable and the insurer does not
	determine under Subchapter C that the claim is payable and pay the
	claim on or before the date the insurer is required to make a
	determination or adjudication of the claim, the insurer shall pay
	the preferred provider making the claim the contracted rate owed on
	the claim plus a penalty in the amount of the lesser of:
	(1)  50 percent of the difference between the billed
	charges, as submitted on the claim, and the contracted rate; or
	(2)  $5,000 [$100,000].
	(b)  If the claim is paid on or after the 46th day and before
	the 91st day after the date the insurer is required to make a
	determination or adjudication of the claim, the insurer shall pay a
	penalty in the amount of the lesser of:
	(1)  100 percent of the difference between the billed
	charges, as submitted on the claim, and the contracted rate; or
	(2)  $10,000 [$200,000].
	(d)  Except as provided by this section, an insurer that
	determines under Subchapter C that a claim is payable, pays only a
	portion of the amount of the claim on or before the date the insurer
	is required to make a determination or adjudication of the claim,
	and pays the balance of the contracted rate owed for the claim after
	that date shall pay to the preferred provider, in addition to the
	contracted amount owed, a penalty on the amount not timely paid in
	the amount of the lesser of:
	(1)  50 percent of the underpaid amount; or
	(2)  $5,000 [$100,000].
	(e)  If the balance of the claim is paid on or after the 46th
	day and before the 91st day after the date the insurer is required
	to make a determination or adjudication of the claim, the insurer
	shall pay a penalty on the balance of the claim in the amount of the
	lesser of:
	(1)  100 percent of the underpaid amount; or
	(2)  $10,000 [$200,000].
	SECTION 8.  Subchapter C-1, Chapter 1301, Insurance Code, is
	amended by adding Section 1301.1371 to read as follows:
	Sec. 1301.1371.  PAYMENT APPEAL DEADLINE. If a contract
	between an insurer and a preferred provider directly or indirectly
	requires that a contractual dispute regarding a post-service
	payment denial or payment dispute be appealed, the insurer may not
	impose a deadline for filing the appeal that is less than 180 days
	after the earlier of:
	(1)  the date of the initial payment or denial notice;
	or
	(2)  the latest date for making a payment or
	notification with respect to the claim under Subchapter C.
	SECTION 9.  Subchapter C-1, Chapter 1301, Insurance Code, is
	amended by adding Section 1301.140 to read as follows:
	Sec. 1301.140.  PAYMENT FOR IMMUNIZATIONS, VACCINES, AND
	SERUMS. (a) A contract between an insurer and a preferred provider
	must disclose the source of the information used to calculate a fee
	payment for an immunization, vaccine, or serum. The information
	must be made readily accessible to the preferred provider, and the
	contract must include an explanation of how the preferred provider
	may access the information.
	(b)  Notwithstanding Section 1301.136(a)(3), an insurer is
	not required to notify a preferred provider, and a contract between
	an insurer and a preferred provider may not directly or indirectly
	require the insurer to notify the preferred provider, before a
	change in a fee payment described by Subsection (a) takes effect if
	the payment change results from a change in information described
	by Subsection (a), the source of which is a third party not
	controlled by the insurer, such as the Centers for Disease Control
	Vaccine Price List.
	(c)  A contract between an insurer and a preferred provider
	must require the insurer to provide notice of a change of a source
	of information described by Subsection (a) used to calculate the
	fee payment for an immunization, vaccine, or serum not later than
	the 90th day before the date the change takes effect.
	SECTION 10.  Sections 843.342(m) and 1301.137(l), Insurance
	Code, are repealed.
	SECTION 11.  It is the intent of the legislature that Section
	16.013, Civil Practice and Remedies Code, as added by this Act,
	applies only to a personal cause of action and does not limit or
	modify the jurisdiction and authority of the commissioner of
	insurance to enforce the prompt payment requirements of Chapters
	843 and 1301, Insurance Code.
	SECTION 12.  (a) Section 16.013, Civil Practice and
	Remedies Code, as added by this Act, applies only to a cause of
	action arising from a claim submitted on or after the effective date
	of this Act. A cause of action arising from a claim submitted
	before the effective date of this Act is governed by the law
	applicable to the claim immediately before the effective date of
	this Act, and that law is continued in effect for that purpose.
	(b)  Except as provided by Subsection (c) of this section,
	Sections 843.337, 843.342, 1301.102, and 1301.137, Insurance Code,
	as amended by this Act, apply only to a claim submitted on or after
	the effective date of this Act. A claim submitted 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.
	(c)  With respect to a claim submitted under a contract with
	a health maintenance organization or insurer, Sections 843.337,
	843.342, 1301.102, and 1301.137, Insurance Code, as amended by this
	Act, apply only to a claim submitted under a contract entered into
	or renewed on or after the effective date of this Act.  A claim
	submitted under a contract entered into or renewed 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.
	(d)  Sections 843.3421, 843.355, 1301.1371, and 1301.140,
	Insurance Code, as added by this Act, apply only to a contract
	entered into or renewed on or after the effective date of this Act.
	A contract entered into or renewed 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 13.  This Act takes effect September 1, 2015.