83R8204 JSL-F
	By: Raymond	H.B. No. 2731

	A BILL TO BE ENTITLED
	AN ACT
	relating to decreasing administrative burdens of Medicaid managed
	care for the state, the managed care organizations, and providers
	under managed care networks.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Section 533.0071, Government Code, is amended to
	read as follows:
	Sec. 533.0071.  ADMINISTRATION OF CONTRACTS.  The
	commission shall make every effort to improve the administration of
	contracts with managed care organizations.  To improve the
	administration of these contracts, the commission shall:
	(1)  ensure that the commission has appropriate
	expertise and qualified staff to effectively manage contracts with
	managed care organizations under the Medicaid managed care program;
	(2)  evaluate options for Medicaid payment recovery
	from managed care organizations if the enrollee dies or is
	incarcerated or if an enrollee is enrolled in more than one state
	program or is covered by another liable third party insurer;
	(3)  maximize Medicaid payment recovery options by
	contracting with private vendors to assist in the recovery of
	capitation payments, payments from other liable third parties, and
	other payments made to managed care organizations with respect to
	enrollees who leave the managed care program;
	(4)  decrease the administrative burdens of managed
	care for the state, the managed care organizations, and the
	providers under managed care networks to the extent that those
	changes are compatible with state law and existing Medicaid managed
	care contracts, including decreasing those burdens by:
	(A)  where possible, decreasing the duplication
	of administrative reporting requirements for the managed care
	organizations, such as requirements for the submission of encounter
	data, quality reports, historically underutilized business
	reports, and claims payment summary reports;
	(B)  allowing managed care organizations to
	provide updated address information directly to the commission for
	correction in the state system;
	(C)  promoting consistency and uniformity among
	managed care organization policies, including policies relating to
	the [preauthorization process,] lengths of hospital stays, filing
	deadlines, levels of care, and case management services;
	(D)  developing efficiency standards and
	requirements for managed care organizations for submitting and
	tracking preauthorization requests for services provided under the
	Medicaid program [reviewing the appropriateness of primary care
	case management requirements in the admission and clinical criteria
	process, such as requirements relating to including a separate
	cover sheet for all communications, submitting handwritten
	communications instead of electronic or typed review processes, and
	admitting patients listed on separate notifications]; [and]
	(E)  providing a single portal through which
	providers in any managed care organization's provider network may
	submit claims; [and]
	(F)  requiring the use of standardized
	application processes and forms for credentialing providers in a
	managed care organization's network; and
	(G)  promoting prompt adjudication of claims
	through provider education on the proper submission of clean claims
	and on appeals;
	(5)  reserve the right to amend the managed care
	organization's process for resolving provider appeals of denials
	based on medical necessity to include an independent review process
	established by the commission for final determination of these
	disputes; and
	(6)  monitor and evaluate a managed care organization's
	compliance with contractual requirements regarding:
	(A)  the reduction of administrative burdens for
	network providers; and
	(B)  complaints regarding claims adjudication or
	payment.
	SECTION 2.  If before implementing any provision of this Act
	a state agency determines that a waiver or authorization from a
	federal agency is necessary for implementation of that provision,
	the agency affected by the provision shall request the waiver or
	authorization and may delay implementing that provision until the
	waiver or authorization is granted.
	SECTION 3.  This Act takes effect September 1, 2013.