Bill Text: TX HB3478 | 2019-2020 | 86th Legislature | Introduced
Bill Title: Relating to an independent medical review of certain determinations by the Health and Human Services Commission or a Medicaid managed care organization.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2019-03-18 - Referred to Human Services [HB3478 Detail]
Download: Texas-2019-HB3478-Introduced.html
86R10759 LED-D | ||
By: Davis of Harris | H.B. No. 3478 |
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relating to an independent medical review of certain determinations | ||
by the Health and Human Services Commission or a Medicaid managed | ||
care organization. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Section 533.00715 to read as follows: | ||
Sec. 533.00715. INDEPENDENT APPEALS PROCEDURE. (a) In | ||
this section, "third-party arbiter" means a third-party medical | ||
review organization that provides objective, unbiased medical | ||
necessity determinations conducted by clinical staff with | ||
education and practice in the same or similar practice area as the | ||
procedure for which an independent determination of medical | ||
necessity is sought. | ||
(b) The commission shall contract with at least three | ||
independent, third-party arbiters to resolve recipient appeals of | ||
any commission or a Medicaid managed care organization adverse | ||
benefit determination or reduction in or denial of health care | ||
services on the basis of medical necessity. | ||
(c) The commission shall establish a common procedure for | ||
appeals. The procedure must provide that a health care service | ||
ordered by a health care provider is presumed medically necessary | ||
and the commission or Medicaid managed care organization bears the | ||
burden of proof to show the health care service is not medically | ||
necessary. The commission shall also establish a procedure for | ||
expedited appeals that allows a third-party arbiter to: | ||
(1) identify an appeal that requires an expedited | ||
resolution; and | ||
(2) resolve the appeal within a specified period. | ||
(d) Subject to Subsection (e), the commission shall ensure | ||
an appeal is randomly assigned to a third-party arbiter. | ||
(e) The commission shall ensure each third-party arbiter | ||
has the necessary medical expertise to resolve an appeal. | ||
(f) A third-party arbiter shall establish and maintain an | ||
Internet portal through which a recipient may track the status and | ||
final disposition of an appeal. | ||
(g) A third-party arbiter shall educate recipients and | ||
employees of Medicaid managed care organizations regarding appeals | ||
processes, options, and proper and improper denials of health care | ||
services on the basis of medical necessity. | ||
(h) A third-party arbiter shall review aggregate denial | ||
data categorized by Medicaid managed care plan to identify trends | ||
and determine whether a Medicaid managed care organization is | ||
disproportionately denying prior authorization requests from a | ||
single provider or set of providers. | ||
SECTION 2. As soon as practicable after the effective date | ||
of this Act, the executive commissioner of the Health and Human | ||
Services Commission shall adopt the rules necessary to implement | ||
this Act. | ||
SECTION 3. If before implementing any provision of this Act | ||
a state agency determines that a waiver or authorization from a | ||
federal agency is necessary for implementation of that provision, | ||
the agency affected by the provision shall request the waiver or | ||
authorization and may delay implementing that provision until the | ||
waiver or authorization is granted. | ||
SECTION 4. This Act takes effect September 1, 2019. |