HB4585 - Relating to the submission, payment, and audit of certain claims for and utilization review of health services, including services provided under the Medicaid managed care and child health plan programs.

  89R7645 SCF-D     By: Spiller H.B. No. 4585       A BILL TO BE ENTITLED   AN ACT   relating to the submission, payment, and audit of certain claims   for and utilization review of health services, including services   provided under the Medicaid managed care and child health plan   programs.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  The heading to Section 540.0265, Government   Code, as effective April 1, 2025, is amended to read as follows:          Sec. 540.0265.   SUBMISSION AND [ PROMPT ] PAYMENT OF CLAIMS.          SECTION 2.  Section 540.0265, Government Code, as effective   April 1, 2025, is amended by amending Subsection (a) and adding   Subsections (c), (d), (e), and (f) to read as follows:          (a)  A contract to which this subchapter applies must require   the contracting Medicaid managed care organization to determine   whether a claim is payable and pay a physician or provider for   health care services provided to a recipient under a Medicaid   managed care plan on any clean claim for payment the organization   receives [ with documentation reasonably necessary for the   organization to process the claim ]:                (1)  not later than:                      (A)  the 10th day after the date the organization   receives the claim if the claim relates to services a nursing   facility, intermediate care facility, or group home provided;                      (B)  the 30th day after the date the organization   receives the claim if the claim relates to the provision of   long-term services and supports not subject to Paragraph (A); and                      (C)  the 45th day after the date the organization   receives the claim if the claim is not subject to Paragraph (A) or   (B); or                (2)  within a period, not to exceed 60 days, specified   by a written agreement between the physician or provider and the   organization.           (c)     A contract to which this subchapter applies must require   a contracting Medicaid managed care organization to disclose to a   physician or provider:                 (1)     the address, including a physical address, where a   claim is sent for processing;                 (2)     the telephone number a physician or provider may   call regarding a question or concern about a claim;                 (3)     the name and physical address of any entity to   which the organization has delegated claim payment functions;                 (4)     the mailing address, physical address, and   telephone number of any separate claims processing center used to   process claims for specific services; and                 (5)     by providing written notice not later than the   61st day before the change, any change to an address, telephone   number, or entity described by Subdivisions (1)-(4).           (d)     A contract to which this subchapter applies must specify   that the contracting Medicaid managed care organization:                 (1)     must allow a physician or provider to submit a   claim for payment during a period of not less than 95 days beginning   on the date the service for which the claim is made was provided;   and                 (2)     is subject to the applicable penalties prescribed   by Section 1301.137, Insurance Code, if the organization fails to   comply with the payment requirements of this section.           (e)  For purposes of this section:                 (1)     a claim a physician or provider submits to a   Medicaid managed care organization is considered to be a clean   claim if the claim meets the requirements of Section 1301.131,   Insurance Code, and rules adopted under that section; and                 (2)     the organization is considered to be the insurer   and the physician or provider is considered to be the preferred   provider with respect to the application of a provision of Chapter   1301, Insurance Code, to the organization, physician, or provider.           (f)     The provisions required under this section may not be   waived, modified, or voided under a contract to which this   subchapter applies or under a contract between a contracting   Medicaid managed care organization and a physician or provider,   except as provided by Subsection (a)(2).          SECTION 3.  Subchapter F, Chapter 540, Government Code, as   effective April 1, 2025, is amended by adding Section 540.02651 to   read as follows:           Sec.   540.02651.     AUDIT OF CLAIM; OVERPAYMENT RECOVERY.   (a)     A contract to which this subchapter applies must require the   contracting Medicaid managed care organization to comply with   Sections 1301.105(b), (c), and (d), 1301.1051, and 1301.132,   Insurance Code.           (b)     For purposes of this section, the contracting Medicaid   managed care organization is considered to be the insurer and the   physician or provider is considered to be the preferred provider   with respect to the application of a provision of Chapter 1301,   Insurance Code, to the organization, physician, or provider.           (c)     The provisions required under this section may not be   waived, modified, or voided under a contract to which this   subchapter applies or under a contract between a contracting   Medicaid managed care organization and a physician or provider.          SECTION 4.  Section 540.0267(a), Government Code, as   effective April 1, 2025, is amended to read as follows:          (a)  A contract to which this subchapter applies must require   the contracting Medicaid managed care organization to develop,   implement, and maintain a system for tracking and resolving   provider appeals related to claims payment. The system must   include a process that requires:                (1)  a tracking mechanism to document the status and   final disposition of each provider's claims payment appeal;                (2)  contracting with physicians who are not network   providers and who are of the same or related specialty as the   appealing physician to resolve claims disputes that:                      (A)  relate to denial on the basis of medical   necessity; and                      (B)  remain unresolved after a provider appeal;                (3)   contracting with an independent review   organization overseen by the commission to resolve claims disputes   in the manner provided by Subchapter I, Chapter 4201, Insurance   Code, that remain unresolved after an appeal under Subdivision (2),   if applicable;                 (4)   the determination of the independent review   organization [ physician ] resolving the dispute to be binding on the   organization and provider; and                 (5)  [ (4) ]  the organization to allow a provider to   initiate an appeal of a claim that has not been paid before the time   prescribed by Section 540.0265(a)(1)(B).          SECTION 5.  Subchapter B, Chapter 62, Health and Safety   Code, is amended by adding Section 62.0551 to read as follows:           Sec.   62.0551.     REQUIRED CONTRACT PROVISIONS. (a)   A   contract between the commission and a child health plan provider   under Section 62.155 must include the requirements specified by   Sections 540.0265, 540.02651, and 540.0267, Government Code.           (b)     Sections 540.0265, 540.02651, and 540.0267, Government   Code, apply to a child health plan provider and health care provider   providing health care services under the child health plan in the   same manner and to the same extent those provisions apply to a   Medicaid managed care organization and a physician or provider   under the Medicaid program.          SECTION 6.  Section 4201.251, Insurance Code, is amended to   read as follows:          Sec. 4201.251.  DELEGATION OF UTILIZATION REVIEW.   (a)  A   utilization review agent may delegate utilization review to   qualified personnel in the hospital or other health care facility   in which the health care services to be reviewed were or are to be   provided.  The delegation does not release the agent from the full   responsibility for compliance with this chapter or other applicable   law, including the conduct of those to whom utilization review has   been delegated.           (b)     A utilization review agent may not delegate utilization   review to an artificial intelligence application or other similar   computer software.          SECTION 7.  Section 4201.252(a), Insurance Code, is amended   to read as follows:          (a)  Personnel employed by or under contract with a   utilization review agent to perform utilization review :                 (1)   must be appropriately trained and qualified and   meet the requirements of this chapter and other applicable law,   including applicable licensing requirements ; and                 (2)     may not delegate utilization review to an   artificial intelligence application or other similar computer   software .          SECTION 8.  (a) Sections 540.0265 and 540.0267, Government   Code, as amended by this Act, and Section 540.02651, Government   Code, as added by this Act, apply only to a contract between the   Health and Human Services Commission and a managed care   organization that is entered into or renewed on or after the   effective date of this Act.          (b)  To the extent permitted by the terms of the contract,   the Health and Human Services Commission shall seek to amend a   contract entered into before the effective date of this Act with a   managed care organization to comply with Sections 540.0265 and   540.0267, Government Code, as amended by this Act, and Section   540.02651, Government Code, as added by this Act.          SECTION 9.  (a) Section 62.0551, Health and Safety Code, as   added by this Act, applies only to a contract between the Health and   Human Services Commission and a child health plan provider under   Chapter 62, Health and Safety Code, that is entered into or renewed   on or after the effective date of this Act.          (b)  To the extent permitted by the terms of the contract,   the Health and Human Services Commission shall seek to amend a   contract entered into before the effective date of this Act with a   child health plan provider to comply with Section 62.0551, Health   and Safety Code, as added by this Act.          SECTION 10.  The changes to Chapter 4201, Insurance Code, as   amended by this Act, apply only to a health benefit plan delivered,   issued for delivery, or renewed on or after January 1, 2026. A   health benefit plan delivered, issued for delivery, or renewed   before January 1, 2026, 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 11.  If before implementing any provision of this   Act a state ag [Text truncated for display. Full text available on Congress.gov.]