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Relating to preauthorization of certain medical care and health care services by certain health benefit plan issuers and to the regulation of utilization review, independent review, and peer review for health benefit plan and workers' compensation coverage.
No significant fiscal implication to the State is anticipated
HB 2327 would require a health maintenance organization (HMO) that uses a preauthorization process to make the requirements and information about the preauthorization readily accessible to enrollees, insureds, physicians, providers, and the general public by posting the requirements and information on their website. This bill includes certain requirements for the posting. HMOs would also be required to provide written notice of new or amended preauthorization requirements to each participating physician or provider, and disclose the new requirements in the HMO's newsletter or network bulletin. If an HMO or insurer fails to comply with the provisions of this bill, then an appeal would be expedited for any health care service affected by the violation.
This bill would require a utilization review agent's utilization review plan, including reconsideration and appeal requirements, to be reviewed by a physician licensed to practice medicine in this state and conducted in accordance with standards developed with input from appropriate health care providers and approved by a licensed physician. It would require the agent before an adverse determination is issued by a utilization review agent who questions the medical necessity, the appropriateness, or the experimental or investigational nature of a health care service, to provide the health care provider who requested the service a reasonable opportunity to discuss with a licensed physician the patient's treatment plan and the clinical basis for the agent's determination.
Texas Action opposes HB 2327 because it would violate limited government and free market principles by placing significant new regulations on the practices of private industry.