86R12187 KFF-D
	By: Martinez	H.B. No. 3212

	A BILL TO BE ENTITLED
	AN ACT
	relating to the procedure for the payment of claims submitted by
	certain providers under the Medicaid managed care program.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Subchapter A, Chapter 533, Government Code, is
	amended by adding Section 533.00553 to read as follows:
	Sec. 533.00553.  REQUIRED PROCEDURES RELATING TO PROCESSING
	CLAIMS BY CERTAIN PROVIDERS. (a)  This section applies to a claim
	submitted to a managed care organization by a physician or hospital
	for the provision of health care services to a recipient receiving
	Medicaid benefits under the organization's managed care plan.
	(b)  A managed care organization may not change the diagnosis
	or treatment code or other description of a health care procedure
	associated with a claim subject to this section to a code or other
	description that will result in a lower reimbursement rate for the
	provider unless:
	(1)  the evaluation of the claim and decision to make
	the change is made by a physician employed by the organization for
	that purpose; and
	(2)  the organization informs the provider in detail of
	the specific reason for the change.
	SECTION 2.  Section 533.00553, Government Code, as added by
	this Act, applies to a claim for payment submitted to a managed care
	organization on or after the effective date of this Act. A claim
	for payment submitted before the effective date of this Act is
	governed by the law in effect on the date the claim was received,
	and the former law is continued in effect for that purpose.
	SECTION 3.  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 4.  This Act takes effect September 1, 2019.