Bill Text: TX HB1273 | 2019-2020 | 86th Legislature | Engrossed
Bill Title: Relating to denial of payment for preauthorized health care or dental care services.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Engrossed - Dead) 2019-05-06 - Referred to Business & Commerce [HB1273 Detail]
Download: Texas-2019-HB1273-Engrossed.html
By: Zedler | H.B. No. 1273 |
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relating to denial of payment for preauthorized health care or | ||
dental care services. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 843.348, Insurance Code, is amended by | ||
adding Subsection (g-1) to read as follows: | ||
(g-1) Nothing in Subsection (g) may be construed to: | ||
(1) authorize a provider to provide health care | ||
services outside of the scope of the provider's practice as defined | ||
by applicable state law; or | ||
(2) require the health maintenance organization to pay | ||
for a health care service provided outside of the scope of a | ||
provider's practice as defined by applicable state law. | ||
SECTION 2. The heading to Chapter 1217, Insurance Code, is | ||
amended to read as follows: | ||
CHAPTER 1217. [ |
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HEALTH CARE OR DENTAL CARE SERVICES | ||
SECTION 3. Chapter 1217, Insurance Code, is amended by | ||
adding Section 1217.008 to read as follows: | ||
Sec. 1217.008. PROHIBITION OF DENIAL OF PAYMENT FOR | ||
PREAUTHORIZED HEALTH CARE OR DENTAL CARE SERVICES. (a) If a health | ||
benefit plan issuer has given prior authorization for health care | ||
or dental care services, the health benefit plan issuer may not deny | ||
or reduce payment to the physician, dentist, or health care | ||
provider for those services based on medical necessity or | ||
appropriateness of care unless the physician, dentist, or health | ||
care provider materially misrepresented the proposed health care or | ||
dental care services or substantially failed to perform the | ||
proposed health care or dental care services. | ||
(b) Nothing in this section limits the liability of a | ||
physician, dentist, or health care provider: | ||
(1) in an action brought under Chapter 36, Human | ||
Resources Code; or | ||
(2) for a violation of state or federal law governing | ||
medical assistance under Chapter 32, Human Resources Code, | ||
including medical assistance delivered through a managed care model | ||
or health benefits provided under the state child health plan | ||
program under Chapter 62, Health and Safety Code. | ||
(c) Subsection (a) does not apply to: | ||
(1) a denial, recoupment, or suspension of or | ||
reduction in a payment to a physician, dentist, or health care | ||
provider made by a managed care organization under the direction of | ||
the Health and Human Services Commission's office of the inspector | ||
general, under the office's authority to prevent, detect, audit, | ||
inspect, review, and investigate fraud, waste, and abuse in the | ||
provision and delivery of all health and human services in the state | ||
under Section 531.102, Government Code; or | ||
(2) a recovery by a managed care organization under | ||
Section 531.1131, Government Code. | ||
(d) Nothing in Subsection (a) may be construed to: | ||
(1) authorize a health care provider to provide health | ||
care services outside of the scope of the health care provider's | ||
practice as defined by applicable state law; or | ||
(2) require the health benefit plan issuer to pay for a | ||
health care service provided outside of the scope of a health care | ||
provider's practice as defined by applicable state law. | ||
SECTION 4. Section 1301.135, Insurance Code, is amended by | ||
adding Subsection (f-1) to read as follows: | ||
(f-1) Nothing in Subsection (f) may be construed to: | ||
(1) authorize a health care provider to provide | ||
medical care or health care services outside of the scope of the | ||
health care provider's practice as defined by applicable state law; | ||
or | ||
(2) require the insurer to pay for a medical care or | ||
health care service provided outside of the scope of a health care | ||
provider's practice as defined by applicable state law. | ||
SECTION 5. This Act takes effect September 1, 2019. |