Bill Text: TX HB3721 | 2019-2020 | 86th Legislature | Engrossed

Bill Title: Relating to an independent review organization to conduct reviews of certain medical necessity determinations under the Medicaid managed care program.

Spectrum: Slight Partisan Bill (Democrat 2-1)

Status: (Engrossed) 2019-05-10 - Referred to Health & Human Services [HB3721 Detail]

Download: Texas-2019-HB3721-Engrossed.html
  By: Deshotel, Raymond, Zedler H.B. No. 3721
  relating to an independent review organization to conduct reviews
  of certain medical necessity determinations under the Medicaid
  managed care program.
         SECTION 1.  Subchapter A, Chapter 533, Government Code, is
  amended by adding Section 533.039 to read as follows:
         Sec. 533.039.  INDEPENDENT REVIEW ORGANIZATIONS. (a) In
  this section, "independent review organization" means an
  organization certified under Chapter 4202, Insurance Code.
         (b)  The commission shall contract with an independent
  review organization to make review determinations with respect to
  disputes at issue in requests for appeal submitted to the
  commission challenging a medical necessity determination of a
  managed care organization that contracts with the commission under
  this chapter, except as provided by Subsection (b-1) or (g). The
  executive commissioner by rule shall determine:
               (1)  the manner in which an independent review
  organization is to settle the disputes;
               (2)  when, subject to Subsection (b-1), in the appeals
  process, an organization may be accessed; and
               (3)  the recourse available after the organization
  makes a review determination.
         (b-1)  With regard to a recipient dispute related to a
  reduction in or denial of services on the basis of medical
  necessity, the commission shall ensure that an independent review
  conducted by an independent review organization under this section
  occurs after the managed care organization has conducted an
  internal appeal and before the Medicaid fair hearing is granted. A
  recipient, or the recipient's parent or legally authorized
  representative, described by this subsection may opt out of being
  subject to an independent review determination under this section
  and instead opt to proceed directly to a Medicaid fair hearing.
         (c)  The commission shall ensure that a contract entered into
  under Subsection (b):
               (1)  requires an independent review organization to
  make a review determination in a timely manner as determined by the
               (2)  provides procedures to protect the
  confidentiality of medical records transmitted to the organization
  for use in conducting an independent review;
               (3)  sets minimum qualifications for and requires the
  independence of each physician or other health care provider making
  a review determination on behalf of the organization;
               (4)  subject to Subsection (c-1), specifies the
  procedures to be used by the organization in making review
               (5)  requires the timely notice to a recipient of the
  results of an independent review, including the clinical basis for
  the review determination;
               (6)  requires that the organization report the
  following aggregate information to the commission in the form and
  manner and at the times prescribed by the commission:
                     (A)  the number of requests for independent
  reviews received by the independent review organization;
                     (B)  the number of independent reviews conducted;
                     (C)  the number of review determinations made:
                           (i)  in favor of a managed care
  organization; and
                           (ii)  in favor of a recipient;
                     (D)  the number of review determinations that
  resulted in a managed care organization deciding to cover the
  service at issue;
                     (E)  a summary of the disputes at issue in
  independent reviews;
                     (F)  a summary of the services that were the
  subject of independent reviews; and
                     (G)  the average time the organization took to
  complete an independent review and make a review determination; and
               (7)  requires that, in addition to the aggregate
  information required by Subdivision (6), the organization include
  in the report the information required by that subdivision
  categorized by managed care organization.
         (c-1)  The commission shall establish a common procedure for
  independent reviews conducted under this section. The procedure
  must provide that a service ordered by a health care provider is
  presumed medically necessary and the managed care organization
  bears the burden of proof to show the service is not medically
  necessary. Medical necessity must be based on publicly available,
  up-to-date, evidence-based, and peer-reviewed clinical criteria.
  The commission shall also establish a procedure for expedited
  reviews that allows the reviewer to identify an appeal that
  requires an expedited resolution.
         (d)  An independent review organization with which the
  commission contracts under this section shall:
               (1)  obtain all information relating to the dispute at
  issue from the managed care organization and the provider in
  accordance with time frames prescribed by the commission;
               (2)  assign a physician or other health care provider
  with appropriate expertise as a reviewer to make a review
               (3)  for each review, perform a check to ensure that the
  organization and the physician or other health care provider
  assigned to make a review determination do not have a conflict of
  interest, as defined in the contract entered into between the
  commission and the organization;
               (4)  communicate procedural rules, approved by the
  commission, and other information regarding the appeals process to
  all parties; and
               (5)  render a timely review determination, as
  determined by the commission.
         (e)  The commission shall ensure that the managed care
  organization, the provider, and the recipient involved in a dispute
  do not have a choice in the reviewer who is assigned to perform the
         (e-1)  An independent review organization's review
  determination of medical necessity establishes the minimum level of
  services a recipient must receive.
         (f)  A managed care organization described by Subsection (b)
  may not have a financial relationship with or ownership interest in
  an independent review organization with which the commission
  contracts. In selecting an independent review organization with
  which to contract, the commission shall avoid conflicts of interest
  by considering and monitoring existing relationships between
  independent review organizations and managed care organizations.
  An independent review organization with which the commission
  contracts must:
               (1)  be overseen by a medical director who is a
  physician licensed in this state; and
               (2)  employ or be able to consult with staff with
  experience in providing private duty nursing services and long-term
  services and supports.
         (g)  This section does not apply to, and an independent
  review organization may not make a review determination with
  respect to, a dispute involving the commission's office of
  inspector general or an action taken at the direction of that
  office, including a dispute relating to:
               (1)  an action taken by a managed care organization at
  the direction of the office under the lock-in program established
  in accordance with 42 C.F.R. Part 431.54(e); or
               (2)  the termination or potential termination of a
  provider's enrollment in a managed care organization's provider
  network at the direction of the office.
         (h)  The executive commissioner shall adopt rules necessary
  to implement this section.
         SECTION 2.  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 3.  This Act takes effect September 1, 2019.