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A BILL TO BE ENTITLED
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AN ACT
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relating to the performance and appeal of utilization review by and |
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under the direction of physicians. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 4201.152, Insurance Code, is amended to |
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read as follows: |
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Sec. 4201.152. UTILIZATION REVIEW UNDER DIRECTION OF |
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PHYSICIAN. A utilization review agent shall conduct utilization |
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review under the direction of a physician licensed to practice |
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medicine in this [by a] state [licensing agency in the United
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States]. |
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SECTION 2. Subchapter D, Chapter 4201, Insurance Code, is |
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amended by adding Section 4201.1525 to read as follows: |
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Sec. 4201.1525. UTILIZATION REVIEW BY PHYSICIANS. (a) A |
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utilization review agent that uses a physician to conduct |
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utilization review may only use a physician licensed to practice |
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medicine in this state. |
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(b) A payor that conducts utilization review on the payor's |
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own behalf is subject to Subsection (a) as if the payor were a |
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utilization review agent. |
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SECTION 3. Section 4201.356, Insurance Code, is amended to |
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read as follows: |
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Sec. 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY |
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REVIEW. (a) The procedures for appealing an adverse determination |
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must provide that a physician licensed to practice medicine in this |
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state makes the decision on the appeal, except as provided by |
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Subsection (b). |
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(b) If not later than the 10th working day after the date an |
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appeal is denied the enrollee's health care provider states in |
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writing good cause for having a particular type of specialty |
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provider review the case, a health care provider licensed in this |
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state who is of the same or a similar specialty as the health care |
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provider who would typically manage the medical or dental |
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condition, procedure, or treatment under consideration for review |
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shall review the decision denying the appeal. The specialty review |
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must be completed within 15 working days of the date the health care |
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provider's request for specialty review is received. |
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SECTION 4. Section 4201.357(a), Insurance Code, is amended |
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to read as follows: |
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(a) The procedures for appealing an adverse determination |
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must include, in addition to the written appeal, a procedure for an |
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expedited appeal of a denial of emergency care or a denial of |
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continued hospitalization. That procedure must include a review |
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by a health care provider who: |
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(1) has not previously reviewed the case; [and] |
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(2) is of the same or a similar specialty as the health |
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care provider who would typically manage the medical or dental |
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condition, procedure, or treatment under review in the appeal; and |
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(3) is licensed in this state. |
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SECTION 5. Section 4201.454, Insurance Code, is amended to |
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read as follows: |
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Sec. 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF |
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PROVIDER OF SAME SPECIALTY. A specialty utilization review agent |
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shall conduct utilization review under the direction of a health |
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care provider who is of the same specialty as the agent and who is |
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licensed or otherwise authorized to provide the specialty health |
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care service in this [by a] state [licensing agency in the United
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States]. |
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SECTION 6. Section 1305.351(d), Insurance Code, is amended |
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to read as follows: |
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(d) A [Notwithstanding Section 4201.152, a] utilization |
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review agent or an insurance carrier that uses doctors to perform |
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reviews of health care services provided under this chapter, |
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including utilization review, or peer reviews under Section |
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408.0231(g), Labor Code, may only use doctors licensed to practice |
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in this state. |
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SECTION 7. Section 408.023(h), Labor Code, is amended to |
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read as follows: |
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(h) A [Notwithstanding Section 4201.152, Insurance Code, a] |
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utilization review agent or an insurance carrier that uses doctors |
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to perform reviews of health care services provided under this |
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subtitle, including utilization review, may only use doctors |
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licensed to practice in this state. |
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SECTION 8. The change in law made by this Act applies only |
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to utilization review that was requested on or after the effective |
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date of this Act. Utilization review that was requested before the |
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effective date of this Act is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 9. This Act takes effect September 1, 2017. |