SB547 - Relating to notice from a health benefit plan issuer regarding a physician's or health care provider's preauthorization exemption status.

      By: Menéndez, Alvarado S.B. No. 547       Hinojosa of Nueces     A BILL TO BE ENTITLED   AN ACT   relating to notice from a health benefit plan issuer regarding a   physician's or health care provider's preauthorization exemption   status.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Section 4201.659(e), Insurance Code, is amended   to read as follows:          (e)  If a physician or provider submits a preauthorization   request for a health care service for which the physician or   provider qualifies for an exemption from preauthorization   requirements under Section 4201.653, the health maintenance   organization or insurer must promptly provide a notice to the   physician or provider that includes:                (1)   a statement that the physician or provider   qualifies for an exemption from preauthorization requirements   under Section 4201.653;                 (2)     a list of the health care services and health   benefit plans to which the exemption applies;                 (3)  a statement of the duration of the exemption [ the   information described by Subsection (d) ]; and                 (4)  [ (2) ]  a notification of the health maintenance   organization's or insurer's payment requirements.          SECTION 2.  Subchapter N, Chapter 4201, Insurance Code, is   amended by adding Section 4201.660 to read as follows:           Sec.   4201.660.     EXEMPTION STATUS NOTIFICATION TO   DEPARTMENT; DATABASE AND REPORT.   (a)   A health maintenance   organization or insurer that uses a preauthorization process for   health care services shall provide written notice to the department   of a physician's or provider's preauthorization exemption status   under this subchapter not later than the 10th day after the date on   which the health maintenance organization or insurer:                 (1)     completes an evaluation of the physician or   provider as required by Section 4201.653(b) and determines whether   the physician or provider qualifies for an exemption;                 (2)     determines that the health maintenance   organization or insurer will continue the physician's or provider's   exemption under Section 4201.653(c);                 (3)     provides notice to the physician or provider of a   determination to rescind the physician's or provider's exemption;   or                 (4)     makes an internal appeal determination or receives   a determination from an independent review organization under   Section 4201.656 affirming or denying the health maintenance   organization's or insurer's determination to rescind the   physician's or provider's exemption.           (b)     The department shall establish and maintain a database   of preauthorization exemption grants, denials, recissions, and   internal appeal and independent review determinations. On the   request of a physician or provider, the department shall provide   the physician or provider with information regarding the   physician's or provider's preauthorization exemption status with   respect to each relevant health maintenance organization or insurer   and with respect to each relevant health care service.           (c)     The department shall collect and compile data   regarding:                 (1)     the number and timing of evaluations being   conducted by each health maintenance organization or insurer under   this subchapter;                 (2)     the number of internal appeals or independent   reviews conducted by or with respect to each health maintenance   organization or insurer under this subchapter;                 (3)     the number of exemptions granted, denied, or   rescinded by each health maintenance organization or insurer, by   provider type and health care service; and                 (4)     the number and outcomes of internal appeals or   independent reviews conducted by or with respect to each health   maintenance organization or insurer.           (d)     The department shall annually prepare a statistical   report reflecting the data collected under Subsection (c) and make   the report available to the public on request.          SECTION 3.  Section 4201.659(d), Insurance Code, is   repealed.          SECTION 4.  Subchapter N, Chapter 4201, Insurance Code, as   amended by this Act, applies only to a determination regarding a   physician's or provider's preauthorization exemption status made on   or after the effective date of this Act.  A determination made   before the effective date of this Act 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 5.  This Act takes effect September 1, 2025.