Bill Text: TX HB1273 | 2019-2020 | 86th Legislature | Engrossed

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Bill Title: Relating to denial of payment for preauthorized health care or dental care services.

Spectrum: Partisan Bill (Republican 2-0)

Status: (Engrossed - Dead) 2019-05-06 - Referred to Business & Commerce [HB1273 Detail]

Download: Texas-2019-HB1273-Engrossed.html

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By: Zedler H.B. No. 1273

A BILL TO BE ENTITLED
AN ACT
relating to denial of payment for preauthorized health care or
dental care services.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 843.348, Insurance Code, is amended by
adding Subsection (g-1) to read as follows:
(g-1) Nothing in Subsection (g) may be construed to:
(1) authorize a provider to provide health care
services outside of the scope of the provider's practice as defined
by applicable state law; or
(2) require the health maintenance organization to pay
for a health care service provided outside of the scope of a
provider's practice as defined by applicable state law.
SECTION 2. The heading to Chapter 1217, Insurance Code, is
amended to read as follows:
CHAPTER 1217. [STANDARD REQUEST FORM FOR] PRIOR AUTHORIZATION OF
HEALTH CARE OR DENTAL CARE SERVICES
SECTION 3. Chapter 1217, Insurance Code, is amended by
adding Section 1217.008 to read as follows:
Sec. 1217.008. PROHIBITION OF DENIAL OF PAYMENT FOR
PREAUTHORIZED HEALTH CARE OR DENTAL CARE SERVICES. (a) If a health
benefit plan issuer has given prior authorization for health care
or dental care services, the health benefit plan issuer may not deny
or reduce payment to the physician, dentist, or health care
provider for those services based on medical necessity or
appropriateness of care unless the physician, dentist, or health
care provider materially misrepresented the proposed health care or
dental care services or substantially failed to perform the
proposed health care or dental care services.
(b) Nothing in this section limits the liability of a
physician, dentist, or health care provider:
(1) in an action brought under Chapter 36, Human
Resources Code; or
(2) for a violation of state or federal law governing
medical assistance under Chapter 32, Human Resources Code,
including medical assistance delivered through a managed care model
or health benefits provided under the state child health plan
program under Chapter 62, Health and Safety Code.
(c) Subsection (a) does not apply to:
(1) a denial, recoupment, or suspension of or
reduction in a payment to a physician, dentist, or health care
provider made by a managed care organization under the direction of
the Health and Human Services Commission's office of the inspector
general, under the office's authority to prevent, detect, audit,
inspect, review, and investigate fraud, waste, and abuse in the
provision and delivery of all health and human services in the state
under Section 531.102, Government Code; or
(2) a recovery by a managed care organization under
Section 531.1131, Government Code.
(d) Nothing in Subsection (a) may be construed to:
(1) authorize a health care provider to provide health
care services outside of the scope of the health care provider's
practice as defined by applicable state law; or
(2) require the health benefit plan issuer to pay for a
health care service provided outside of the scope of a health care
provider's practice as defined by applicable state law.
SECTION 4. Section 1301.135, Insurance Code, is amended by
adding Subsection (f-1) to read as follows:
(f-1) Nothing in Subsection (f) may be construed to:
(1) authorize a health care provider to provide
medical care or health care services outside of the scope of the
health care provider's practice as defined by applicable state law;
or
(2) require the insurer to pay for a medical care or
health care service provided outside of the scope of a health care
provider's practice as defined by applicable state law.
SECTION 5. This Act takes effect September 1, 2019.