Bill Text: TX HB2292 | 2011-2012 | 82nd Legislature | Enrolled
Bill Title: Relating to payment of claims to pharmacies and pharmacists.
Spectrum: Slight Partisan Bill (Republican 2-1)
Status: (Passed) 2011-06-17 - Effective on 9/1/11 [HB2292 Detail]
Download: Texas-2011-HB2292-Enrolled.html
H.B. No. 2292 |
|
||
relating to payment of claims to pharmacies and pharmacists. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 843.002, Insurance Code, is amended by | ||
amending Subdivision (9-a) and adding Subdivision (9-b) to read as | ||
follows: | ||
(9-a) "Extrapolation" means a mathematical process or | ||
technique used by a health maintenance organization or pharmacy | ||
benefit manager that administers pharmacy claims for a health | ||
maintenance organization in the audit of a pharmacy or pharmacist | ||
to estimate audit results or findings for a larger batch or group of | ||
claims not reviewed by the health maintenance organization or | ||
pharmacy benefit manager. | ||
(9-b) "Freestanding emergency medical care facility" | ||
means a facility licensed under Chapter 254, Health and Safety | ||
Code. | ||
SECTION 2. Section 843.338, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 843.338. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except | ||
as provided by Sections [ |
||
than the 45th day after the date on which a health maintenance | ||
organization receives a clean claim from a participating physician | ||
or provider in a nonelectronic format or the 30th day after the date | ||
the health maintenance organization receives a clean claim from a | ||
participating physician or provider that is electronically | ||
submitted, the health maintenance organization shall make a | ||
determination of whether the claim is payable and: | ||
(1) if the health maintenance organization determines | ||
the entire claim is payable, pay the total amount of the claim in | ||
accordance with the contract between the physician or provider and | ||
the health maintenance organization; | ||
(2) if the health maintenance organization determines | ||
a portion of the claim is payable, pay the portion of the claim that | ||
is not in dispute and notify the physician or provider in writing | ||
why the remaining portion of the claim will not be paid; or | ||
(3) if the health maintenance organization determines | ||
that the claim is not payable, notify the physician or provider in | ||
writing why the claim will not be paid. | ||
SECTION 3. Section 843.339, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 843.339. DEADLINE FOR ACTION ON [ |
||
CLAIMS; PAYMENT. (a) A [ |
||
|
||
that administers pharmacy claims for the health maintenance | ||
organization, that affirmatively adjudicates a pharmacy claim that | ||
is electronically submitted[ |
||
shall pay the total amount of the claim through electronic funds | ||
transfer not later than the 18th day after the date on which the | ||
claim was affirmatively adjudicated. | ||
(b) A health maintenance organization, or a pharmacy | ||
benefit manager that administers pharmacy claims for the health | ||
maintenance organization, that affirmatively adjudicates a | ||
pharmacy claim that is not electronically submitted shall pay the | ||
total amount of the claim not later than the 21st day after the date | ||
on which the claim was affirmatively adjudicated. | ||
SECTION 4. Subchapter J, Chapter 843, Insurance Code, is | ||
amended by adding Section 843.3401 to read as follows: | ||
Sec. 843.3401. AUDIT OF PHARMACIST OR PHARMACY. (a) A | ||
health maintenance organization or a pharmacy benefit manager that | ||
administers pharmacy claims for the health maintenance | ||
organization may not use extrapolation to complete the audit of a | ||
provider who is a pharmacist or pharmacy. A health maintenance | ||
organization may not require extrapolation audits as a condition of | ||
participation in the health maintenance organization's contract, | ||
network, or program for a provider who is a pharmacist or pharmacy. | ||
(b) A health maintenance organization or a pharmacy benefit | ||
manager that administers pharmacy claims for the health maintenance | ||
organization that performs an on-site audit under this chapter of a | ||
provider who is a pharmacist or pharmacy shall provide the provider | ||
reasonable notice of the audit and accommodate the provider's | ||
schedule to the greatest extent possible. The notice required | ||
under this subsection must be in writing and must be sent by | ||
certified mail to the provider not later than the 15th day before | ||
the date on which the on-site audit is scheduled to occur. | ||
SECTION 5. Section 843.344, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 843.344. APPLICABILITY OF SUBCHAPTER TO ENTITIES | ||
CONTRACTING WITH HEALTH MAINTENANCE ORGANIZATION. This subchapter | ||
applies to a person, including a pharmacy benefit manager, with | ||
whom a health maintenance organization contracts to: | ||
(1) process or pay claims; | ||
(2) obtain the services of physicians and providers to | ||
provide health care services to enrollees; or | ||
(3) issue verifications or preauthorizations. | ||
SECTION 6. Subchapter J, Chapter 843, Insurance Code, is | ||
amended by adding Section 843.354 to read as follows: | ||
Sec. 843.354. LEGISLATIVE DECLARATION. It is the intent of | ||
the legislature that the requirements contained in this subchapter | ||
regarding payment of claims to providers who are pharmacists or | ||
pharmacies apply to all health maintenance organizations and | ||
pharmacy benefit managers unless otherwise prohibited by federal | ||
law. | ||
SECTION 7. Section 1301.001, Insurance Code, is amended by | ||
amending Subdivision (1) and adding Subdivision (1-a) to read as | ||
follows: | ||
(1) "Extrapolation" means a mathematical process or | ||
technique used by an insurer or pharmacy benefit manager that | ||
administers pharmacy claims for an insurer in the audit of a | ||
pharmacy or pharmacist to estimate audit results or findings for a | ||
larger batch or group of claims not reviewed by the insurer or | ||
pharmacy benefit manager. | ||
(1-a) "Health care provider" means a practitioner, | ||
institutional provider, or other person or organization that | ||
furnishes health care services and that is licensed or otherwise | ||
authorized to practice in this state. The term includes a | ||
pharmacist and a pharmacy. The term does not include a physician. | ||
SECTION 8. Section 1301.103, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 1301.103. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except | ||
as provided by Sections 1301.104 and [ |
||
than the 45th day after the date an insurer receives a clean claim | ||
from a preferred provider in a nonelectronic format or the 30th day | ||
after the date an insurer receives a clean claim from a preferred | ||
provider that is electronically submitted, the insurer shall make a | ||
determination of whether the claim is payable and: | ||
(1) if the insurer determines the entire claim is | ||
payable, pay the total amount of the claim in accordance with the | ||
contract between the preferred provider and the insurer; | ||
(2) if the insurer determines a portion of the claim is | ||
payable, pay the portion of the claim that is not in dispute and | ||
notify the preferred provider in writing why the remaining portion | ||
of the claim will not be paid; or | ||
(3) if the insurer determines that the claim is not | ||
payable, notify the preferred provider in writing why the claim | ||
will not be paid. | ||
SECTION 9. Section 1301.104, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 1301.104. DEADLINE FOR ACTION ON [ |
||
CLAIMS; PAYMENT. (a) An [ |
||
|
||
pharmacy claims for the insurer under a preferred provider benefit | ||
plan, that affirmatively adjudicates a pharmacy claim that is | ||
electronically submitted[ |
||
of the claim through electronic funds transfer not later than the | ||
18th day after the date on which the claim was affirmatively | ||
adjudicated. | ||
(b) An insurer, or a pharmacy benefit manager that | ||
administers pharmacy claims for the insurer under a preferred | ||
provider benefit plan, that affirmatively adjudicates a pharmacy | ||
claim that is not electronically submitted shall pay the total | ||
amount of the claim not later than the 21st day after the date on | ||
which the claim was affirmatively adjudicated. | ||
SECTION 10. Subchapter C, Chapter 1301, Insurance Code, is | ||
amended by adding Section 1301.1041 to read as follows: | ||
Sec. 1301.1041. AUDIT OF PHARMACIST OR PHARMACY. (a) An | ||
insurer or a pharmacy benefit manager that administers pharmacy | ||
claims for the insurer may not use extrapolation to complete the | ||
audit of a preferred provider that is a pharmacist or pharmacy. An | ||
insurer may not require extrapolation audits as a condition of | ||
participation in the insurer's contract, network, or program for a | ||
preferred provider that is a pharmacist or pharmacy. | ||
(b) An insurer or a pharmacy benefit manager that | ||
administers pharmacy claims for the insurer that performs an | ||
on-site audit of a preferred provider who is a pharmacist or | ||
pharmacy shall provide the provider reasonable notice of the audit | ||
and accommodate the provider's schedule to the greatest extent | ||
possible. The notice required under this subsection must be in | ||
writing and must be sent by certified mail to the preferred provider | ||
not later than the 15th day before the date on which the on-site | ||
audit is scheduled to occur. | ||
SECTION 11. Section 1301.109, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 1301.109. APPLICABILITY TO ENTITIES CONTRACTING WITH | ||
INSURER. This subchapter applies to a person, including a pharmacy | ||
benefit manager, with whom an insurer contracts to: | ||
(1) process or pay claims; | ||
(2) obtain the services of physicians and health care | ||
providers to provide health care services to insureds; or | ||
(3) issue verifications or preauthorizations. | ||
SECTION 12. Subchapter C-1, Chapter 1301, Insurance Code, | ||
is amended by adding Section 1301.139 to read as follows: | ||
Sec. 1301.139. LEGISLATIVE DECLARATION. It is the intent | ||
of the legislature that the requirements contained in this | ||
subchapter regarding payment of claims to preferred providers who | ||
are pharmacists or pharmacies apply to all insurers and pharmacy | ||
benefit managers unless otherwise prohibited by federal law. | ||
SECTION 13. (a) With respect to pharmacy benefits provided | ||
under a contract, the changes in law made by this Act apply only to a | ||
contract entered into or renewed on or after the effective date of | ||
this Act and payment for pharmacy benefits provided under the | ||
contract. A contract entered into before the effective date of this | ||
Act and not renewed or that was last renewed before the effective | ||
date of this Act, and payment for pharmacy benefits provided under | ||
the contract, are governed by the law in effect immediately before | ||
the effective date of this Act, and that law is continued in effect | ||
for that purpose. | ||
(b) With respect to payment for pharmacy benefits not | ||
provided under a contract to which Subsection (a) of this section | ||
applies, the changes in law made by this Act apply only to payment | ||
for benefits provided on or after the effective date of this Act. | ||
Payment for benefits not subject to Subsection (a) of this section | ||
and provided before the effective date of this Act is governed by | ||
the law in effect immediately before the effective date of this Act, | ||
and that law is continued in effect for that purpose. | ||
(c) Sections 843.3401 and 1301.1041, Insurance Code, as | ||
added by this Act, apply to an audit of a pharmacist or pharmacy | ||
performed on or after the effective date of this Act unless the | ||
audit is performed under a contract that is entered into before the | ||
effective date of this Act and that, at the time of the audit, has | ||
not been renewed or was last renewed before the effective date of | ||
this Act. | ||
SECTION 14. This Act takes effect September 1, 2011. | ||
______________________________ | ______________________________ | |
President of the Senate | Speaker of the House | |
I certify that H.B. No. 2292 was passed by the House on May | ||
13, 2011, by the following vote: Yeas 138, Nays 0, 1 present, not | ||
voting. | ||
______________________________ | ||
Chief Clerk of the House | ||
I certify that H.B. No. 2292 was passed by the Senate on May | ||
24, 2011, by the following vote: Yeas 31, Nays 0 | ||
. | ||
______________________________ | ||
Secretary of the Senate | ||
APPROVED: _____________________ | ||
Date | ||
_____________________ | ||
Governor |