HB3042 - Relating to laboratory claim integrity programs for health benefit plans.

  89R2337 RDR-F     By: Paul H.B. No. 3042       A BILL TO BE ENTITLED   AN ACT   relating to laboratory claim integrity programs for health benefit   plans.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Subtitle A, Title 8, Insurance Code, is amended   by adding Chapter 1224 to read as follows:   CHAPTER 1224. LABORATORY CLAIM INTEGRITY PROGRAMS           Sec. 1224.001.  DEFINITIONS. In this chapter:                 (1)     "Clinical laboratory test" means the examination   of a sample of biological material taken from a human body ordered   by a physician or health care provider for use in the diagnosis,   prevention, or treatment of a disease or the identification or   assessment of a medical or physical condition.                 (2)     "Enrollee" means an individual enrolled in a   health benefit plan.                 (3)     "Health benefit plan issuer" means an entity   authorized under this code or another insurance law of this state to   provide benefits for health care services, including:                       (A)  an insurance company;                       (B)     a group hospital service corporation   operating under Chapter 842;                       (C)     a health maintenance organization operating   under Chapter 843;                       (D)     an approved nonprofit health corporation   that holds a certificate of authority under Chapter 844;                       (E)     a multiple employer welfare arrangement that   holds a certificate of authority under Chapter 846; or                       (F)     a fraternal benefit society operating under   Chapter 885.                 (4)     "Laboratory claim integrity program" means a claim   editing program that identifies wasteful clinical laboratory tests   based on the health benefit plan's clinical laboratory testing   reimbursement policies.                 (5)     "Person" means an individual, corporation, trust,   partnership, association, or any other legal entity.           Sec.   1224.002.   REGISTRATION FOR PERSON PROVIDING   LABORATORY CLAIM INTEGRITY PROGRAM. (a) A person shall register   with the department before providing a laboratory claim integrity   program in this state. The registration is valid for three years and   may be renewed.           (b)     The commissioner shall promulgate a form to be submitted   under this section for the initial registration and renewal of a   registration. The form for initial registration must include:                 (1)     the name, address, telephone number, and e-mail   address of the applicant;                 (2)     the name and address of an agent for service of   process in this state; and                 (3)     a summary of the laboratory claim integrity   program.           (c)     Upon request by the commissioner, a person registered   under this section shall identify each health benefit plan issuer   who has contracted with the person for the provision of a laboratory   claim integrity program.           Sec.   1224.003.     EXEMPTIONS. (a)   This chapter does not   require registration as a person providing a laboratory claim   integrity program by:                 (1)  a health benefit plan issuer; or                 (2)     a utilization review agent that has been issued a   certificate of registration under Chapter 4201.           (b)     The activities of a laboratory claim integrity program   are exempt from the requirements of Chapter 4201.           Sec.   1224.004.   REQUIREMENTS FOR LABORATORY CLAIM INTEGRITY   PROGRAMS. (a)   A laboratory claim integrity program shall:                 (1)     apply only objective, evidence-based, and   population-based clinical laboratory testing reimbursement   policies; and                 (2)     include a summary of the program or an electronic   link to a summary of the program on its public Internet website.           (b)  A laboratory claim integrity program may not:                 (1)     require the use of clinical decision support   software by an enrollee's physician or health care provider before   the physician or provider orders a clinical laboratory test for the   enrollee;                 (2)     restrict, limit, or influence a clinical   laboratory test provider's choice of electronic health record   software, electronic medical record software, or practice   management software;                 (3)     restrict, limit, or influence a clinical   laboratory test provider's choice of third-party claim-filing   service, billing service, or electronic data interchange   clearinghouse company;                 (4)     disclose an enrollee's protected health   information unless the disclosure is authorized by the enrollee or   the enrollee's authorized representative or is permitted without   authorization under the Health Insurance Portability and   Accountability Act of 1996 (42 U.S.C. Section 1320d et seq.) or   under Section 602.053; or                 (5)     hold a delegation from a health benefit plan   issuer to make claim determinations.           Sec.   1224.005.     PROGRAM ACTIONS NOT ADVERSE DETERMINATION.   A denial or reduction in payment of a claim that is identified by a   laboratory claim integrity program as not meeting the requirements   of an applicable health benefit plan clinical laboratory testing   reimbursement policy is not an adverse determination for purposes   of Chapter 4201.          SECTION 2.  Chapter 1224, Insurance Code, as added by this   Act, applies only to a laboratory claim integrity program contract   that is entered into or renewed on or after January 1, 2026.          SECTION 3.  This Act takes effect September 1, 2025.