Relating to notice from a health benefit plan issuer regarding a physician's or health care provider's preauthorization exemption status.

89(R) SB 547 - Engrossed version - Bill Text

By: Menéndez, Alvarado

S.B. No. 547

Hinojosa of Nueces

A BILL TO BE ENTITLED

AN ACT

relating to notice from a health benefit plan issuer regarding a

physician's or health care provider's preauthorization exemption

status.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 4201.659(e), Insurance Code, is amended

to read as follows:

(e) If a physician or provider submits a preauthorization

request for a health care service for which the physician or

provider qualifies for an exemption from preauthorization

requirements under Section 4201.653, the health maintenance

organization or insurer must promptly provide a notice to the

physician or provider that includes:

(1)
a statement that the physician or provider

qualifies for an exemption from preauthorization requirements

under Section 4201.653;

(2)

a list of the health care services and health

benefit plans to which the exemption applies;

(3) a statement of the duration of the exemption
[
the

information described by Subsection (d)
]; and

(4)
[
(2)
] a notification of the health maintenance

organization's or insurer's payment requirements.

SECTION 2. Subchapter N, Chapter 4201, Insurance Code, is

amended by adding Section 4201.660 to read as follows:

Sec.

4201.660.

EXEMPTION STATUS NOTIFICATION TO

DEPARTMENT; DATABASE AND REPORT.

(a)

A health maintenance

organization or insurer that uses a preauthorization process for

health care services shall provide written notice to the department

of a physician's or provider's preauthorization exemption status

under this subchapter not later than the 10th day after the date on

which the health maintenance organization or insurer:

(1)

completes an evaluation of the physician or

provider as required by Section 4201.653(b) and determines whether

the physician or provider qualifies for an exemption;

(2)

determines that the health maintenance

organization or insurer will continue the physician's or provider's

exemption under Section 4201.653(c);

(3)

provides notice to the physician or provider of a

determination to rescind the physician's or provider's exemption;

or

(4)

makes an internal appeal determination or receives

a determination from an independent review organization under

Section 4201.656 affirming or denying the health maintenance

organization's or insurer's determination to rescind the

physician's or provider's exemption.

(b)

The department shall establish and maintain a database

of preauthorization exemption grants, denials, recissions, and

internal appeal and independent review determinations. On the

request of a physician or provider, the department shall provide

the physician or provider with information regarding the

physician's or provider's preauthorization exemption status with

respect to each relevant health maintenance organization or insurer

and with respect to each relevant health care service.

(c)

The department shall collect and compile data

regarding:

(1)

the number and timing of evaluations being

conducted by each health maintenance organization or insurer under

this subchapter;

(2)

the number of internal appeals or independent

reviews conducted by or with respect to each health maintenance

organization or insurer under this subchapter;

(3)

the number of exemptions granted, denied, or

rescinded by each health maintenance organization or insurer, by

provider type and health care service; and

(4)

the number and outcomes of internal appeals or

independent reviews conducted by or with respect to each health

maintenance organization or insurer.

(d)

The department shall annually prepare a statistical

report reflecting the data collected under Subsection (c) and make

the report available to the public on request.

SECTION 3. Section 4201.659(d), Insurance Code, is

repealed.

SECTION 4. Subchapter N, Chapter 4201, Insurance Code, as

amended by this Act, applies only to a determination regarding a

physician's or provider's preauthorization exemption status made on

or after the effective date of this Act. A determination made

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 5. This Act takes effect September 1, 2025.