87R994 SCL-D
	By: Johnson of Dallas	H.B. No. 1145

	A BILL TO BE ENTITLED
	AN ACT
	relating to utilization review requirements for a health care
	service provided by a network physician or provider.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Subchapter J, Chapter 843, Insurance Code, is
	amended by adding Section 843.355 to read as follows:
	Sec. 843.355.  UTILIZATION REVIEW FOR PARTICIPATING
	PHYSICIAN OR PROVIDER PROHIBITED. A health maintenance
	organization may not require utilization review, including a
	preauthorization determination that a health care service is
	medically necessary and appropriate, of a health care service
	provided to an enrollee by a participating physician or provider.
	SECTION 2.  Subchapter C-1, Chapter 1301, Insurance Code, is
	amended by adding Section 1301.1345 to read as follows:
	Sec. 1301.1345.  UTILIZATION REVIEW FOR PREFERRED PHYSICIAN
	OR PROVIDER PROHIBITED. (a) In this section, "utilization review"
	has the meaning assigned by Section 4201.002.
	(b)  An insurer may not require utilization review,
	including preauthorization, of a medical care or health care
	service provided to an insured by a preferred physician or
	provider.
	SECTION 3.  The heading to Section 1301.135, Insurance Code,
	is amended to read as follows:
	Sec. 1301.135.  PREAUTHORIZATION OF MEDICAL AND HEALTH CARE
	SERVICES FOR NONPREFERRED PHYSICIAN OR PROVIDER.
	SECTION 4.  Sections 1301.135(d) and (f), Insurance Code,
	are amended to read as follows:
	(d)  If [the] proposed medical care or health care services
	involve inpatient care and the insurer requires preauthorization as
	a condition of payment of a nonpreferred provider, the insurer
	shall review the request and issue a length of stay for the
	admission into a health care facility based on the recommendation
	of the patient's nonpreferred [physician or health care] provider
	and the insurer's written medically accepted screening criteria and
	review procedures. If the proposed medical or health care services
	are to be provided to a patient who is an inpatient in a health care
	facility at the time the services are proposed, the insurer shall
	review the request and issue a determination indicating whether
	proposed services are preauthorized within 24 hours of the request
	by the nonpreferred physician or provider.
	(f)  If an insurer has preauthorized medical care or health
	care services, the insurer may not deny or reduce payment to the
	nonpreferred physician or health care provider for those services
	based on medical necessity or appropriateness of care unless the
	nonpreferred physician or provider has materially misrepresented
	the proposed medical or health care services or has substantially
	failed to perform the proposed medical or health care services.
	SECTION 5.  Section 1301.1351(d), Insurance Code, is amended
	to read as follows:
	(d)  If a requirement or information described by Subsection
	(a) is licensed, proprietary, or copyrighted material that the
	insurer has received from a third party with which the insurer has
	contracted, to comply with a posting requirement described by
	Subsection (b), the insurer may, instead of making that information
	publicly available on the insurer's Internet website, provide the
	material to a nonpreferred [physician or health care] provider who
	submits a preauthorization request using a nonpublic secured
	Internet website link or other protected, nonpublic electronic
	means.
	SECTION 6.  The following provisions of the Insurance Code
	are repealed:
	(1)  Section 843.348;
	(2)  Section 843.3481;
	(3)  Section 843.3482;
	(4)  Section 843.3483; and
	(5)  Sections 1301.135(a), (b), and (c).
	SECTION 7.  The changes in law made by this Act apply only to
	a health benefit plan delivered, issued for delivery, or renewed on
	or after January 1, 2022. A health benefit plan delivered, issued
	for delivery, or renewed before January 1, 2022, 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 8.  This Act takes effect September 1, 2021.