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  89R4401 SCR-F     By: Muñoz, Jr. H.B. No. 1641       A BILL TO BE ENTITLED   AN ACT   relating to the use of extrapolation by a health maintenance   organization or an insurer to audit claims.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Section 843.010, Insurance Code, as effective   April 1, 2025, is amended to read as follows:          Sec. 843.010.  APPLICABILITY OF CERTAIN PROVISIONS TO   GOVERNMENTAL HEALTH BENEFIT PLANS.  Sections 843.306(f) , 843.322,   and 843.363(a)(4) do not apply to coverage under:                (1)  the child health plan program under Chapter 62,   Health and Safety Code, or the health benefits plan for children   under Chapter 63, Health and Safety Code; or                (2)  a Medicaid program, including a Medicaid managed   care program operated under Chapter 540 or 540A, Government Code,   as applicable.          SECTION 2.  Subchapter I, Chapter 843, Insurance Code, is   amended by adding Section 843.322 to read as follows:           Sec.   843.322.     USE OF EXTRAPOLATION PROHIBITED.   (a)   In this   section, "extrapolation" means a mathematical process or technique   used by a health maintenance organization in the audit of a   participating physician or provider to estimate audit results or   findings for a larger batch or group of claims not reviewed by the   health maintenance organization.           (b)     A health maintenance organization may not use   extrapolation to complete an audit of a participating physician or   provider.   Any additional payment due a participating physician or   provider or any refund due the health maintenance organization must   be based on the actual overpayment or underpayment and may not be   based on an extrapolation.          SECTION 3.  Subchapter B, Chapter 1301, Insurance Code, is   amended by adding Section 1301.0643 to read as follows:           Sec.   1301.0643.     USE OF EXTRAPOLATION PROHIBITED.   (a)   In   this section, "extrapolation" means a mathematical process or   technique used by an insurer in the audit of a preferred provider to   estimate audit results or findings for a larger batch or group of   claims not reviewed by the insurer.           (b)     An insurer may not use extrapolation to complete an   audit of a preferred provider.   Any additional payment due a   preferred provider or any refund due the insurer must be based on   the actual overpayment or underpayment and may not be based on an   extrapolation.          SECTION 4.  The change in law made by this Act applies only   to the audit of a physician or provider under a contract with an   insurer or health maintenance organization entered into or renewed   on or after the effective date of this Act.          SECTION 5.  This Act takes effect September 1, 2025.