Bill Text: TX HB2345 | 2017-2018 | 85th Legislature | Introduced
Bill Title: Relating to the performance and appeal of utilization review by and under the direction of physicians.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2017-05-04 - Committee report sent to Calendars [HB2345 Detail]
Download: Texas-2017-HB2345-Introduced.html
85R7231 SCL-D | ||
By: Workman | H.B. No. 2345 |
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relating to the performance and appeal of utilization review by and | ||
under the direction of physicians. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 4201.152, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 4201.152. UTILIZATION REVIEW UNDER DIRECTION OF | ||
PHYSICIAN. A utilization review agent shall conduct utilization | ||
review under the direction of a physician licensed to practice | ||
medicine in this [ |
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SECTION 2. Subchapter D, Chapter 4201, Insurance Code, is | ||
amended by adding Section 4201.1525 to read as follows: | ||
Sec. 4201.1525. UTILIZATION REVIEW BY PHYSICIANS. (a) A | ||
utilization review agent that uses a physician to conduct | ||
utilization review may only use a physician licensed to practice | ||
medicine in this state. | ||
(b) A payor that conducts utilization review on the payor's | ||
own behalf is subject to Subsection (a) as if the payor were a | ||
utilization review agent. | ||
SECTION 3. Section 4201.356, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY | ||
REVIEW. (a) The procedures for appealing an adverse determination | ||
must provide that a physician licensed to practice medicine in this | ||
state makes the decision on the appeal, except as provided by | ||
Subsection (b). | ||
(b) If not later than the 10th working day after the date an | ||
appeal is denied the enrollee's health care provider states in | ||
writing good cause for having a particular type of specialty | ||
provider review the case, a health care provider licensed in this | ||
state who is of the same or a similar specialty as the health care | ||
provider who would typically manage the medical or dental | ||
condition, procedure, or treatment under consideration for review | ||
shall review the decision denying the appeal. The specialty review | ||
must be completed within 15 working days of the date the health care | ||
provider's request for specialty review is received. | ||
SECTION 4. Section 4201.357(a), Insurance Code, is amended | ||
to read as follows: | ||
(a) The procedures for appealing an adverse determination | ||
must include, in addition to the written appeal, a procedure for an | ||
expedited appeal of a denial of emergency care or a denial of | ||
continued hospitalization. That procedure must include a review | ||
by a health care provider who: | ||
(1) has not previously reviewed the case; [ |
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(2) is of the same or a similar specialty as the health | ||
care provider who would typically manage the medical or dental | ||
condition, procedure, or treatment under review in the appeal; and | ||
(3) is licensed in this state. | ||
SECTION 5. Section 4201.454, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF | ||
PROVIDER OF SAME SPECIALTY. A specialty utilization review agent | ||
shall conduct utilization review under the direction of a health | ||
care provider who is of the same specialty as the agent and who is | ||
licensed or otherwise authorized to provide the specialty health | ||
care service in this [ |
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SECTION 6. Section 1305.351(d), Insurance Code, is amended | ||
to read as follows: | ||
(d) A [ |
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review agent or an insurance carrier that uses doctors to perform | ||
reviews of health care services provided under this chapter, | ||
including utilization review, or peer reviews under Section | ||
408.0231(g), Labor Code, may only use doctors licensed to practice | ||
in this state. | ||
SECTION 7. Section 408.023(h), Labor Code, is amended to | ||
read as follows: | ||
(h) A [ |
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utilization review agent or an insurance carrier that uses doctors | ||
to perform reviews of health care services provided under this | ||
subtitle, including utilization review, may only use doctors | ||
licensed to practice in this state. | ||
SECTION 8. The change in law made by this Act applies only | ||
to utilization review that was requested on or after the effective | ||
date of this Act. Utilization review that was requested 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 9. This Act takes effect September 1, 2017. |