85R7231 SCL-D     By: Buckingham S.B. No. 2030       A BILL TO BE ENTITLED   AN ACT   relating to the performance and appeal of utilization review by and   under the direction of physicians.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Section 4201.152, Insurance Code, is amended to   read as follows:          Sec. 4201.152.  UTILIZATION REVIEW UNDER DIRECTION OF   PHYSICIAN. A utilization review agent shall conduct utilization   review under the direction of a physician licensed to practice   medicine in this [by a] state [licensing agency in the United   States].          SECTION 2.  Subchapter D, Chapter 4201, Insurance Code, is   amended by adding Section 4201.1525 to read as follows:          Sec. 4201.1525.  UTILIZATION REVIEW BY PHYSICIANS. (a) A   utilization review agent that uses a physician to conduct   utilization review may only use a physician licensed to practice   medicine in this state.          (b)  A payor that conducts utilization review on the payor's   own behalf is subject to Subsection (a) as if the payor were a   utilization review agent.          SECTION 3.  Section 4201.356, Insurance Code, is amended to   read as follows:          Sec. 4201.356.  DECISION BY PHYSICIAN REQUIRED; SPECIALTY   REVIEW. (a) The procedures for appealing an adverse determination   must provide that a physician licensed to practice medicine in this   state makes the decision on the appeal, except as provided by   Subsection (b).          (b)  If not later than the 10th working day after the date an   appeal is denied the enrollee's health care provider states in   writing good cause for having a particular type of specialty   provider review the case, a health care provider licensed in this   state who is of the same or a similar specialty as the health care   provider who would typically manage the medical or dental   condition, procedure, or treatment under consideration for review   shall review the decision denying the appeal. The specialty review   must be completed within 15 working days of the date the health care   provider's request for specialty review is received.          SECTION 4.  Section 4201.357(a), Insurance Code, is amended   to read as follows:          (a)  The procedures for appealing an adverse determination   must include, in addition to the written appeal, a procedure for an   expedited appeal of a denial of emergency care or a denial of   continued hospitalization.  That procedure must include a review   by a health care provider who:                (1)  has not previously reviewed the case; [and]                (2)  is of the same or a similar specialty as the health   care provider who would typically manage the medical or dental   condition, procedure, or treatment under review in the appeal; and                (3)  is licensed in this state.          SECTION 5.  Section 4201.454, Insurance Code, is amended to   read as follows:          Sec. 4201.454.  UTILIZATION REVIEW UNDER DIRECTION OF   PROVIDER OF SAME SPECIALTY. A specialty utilization review agent   shall conduct utilization review under the direction of a health   care provider who is of the same specialty as the agent and who is   licensed or otherwise authorized to provide the specialty health   care service in this [by a] state [licensing agency in the United   States].          SECTION 6.  Section 1305.351(d), Insurance Code, is amended   to read as follows:          (d)  A [Notwithstanding Section 4201.152, a] utilization   review agent or an insurance carrier that uses doctors to perform   reviews of health care services provided under this chapter,   including utilization review, or peer reviews under Section   408.0231(g), Labor Code, may only use doctors licensed to practice   in this state.          SECTION 7.  Section 408.023(h), Labor Code, is amended to   read as follows:          (h)  A [Notwithstanding Section 4201.152, Insurance Code, a]   utilization review agent or an insurance carrier that uses doctors   to perform reviews of health care services provided under this   subtitle, including utilization review, may only use doctors   licensed to practice in this state.          SECTION 8.  The change in law made by this Act applies only   to utilization review that was requested on or after the effective   date of this Act. Utilization review that was requested 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 9.  This Act takes effect September 1, 2017.