Paul Bill Exempts Lab Claim-Editing Vendors From Utilization Review Law

The text as introduced · 741 words

89R2337 RDR-F

By: Paul
H.B. No. 3042

A BILL TO BE ENTITLED

AN ACT

relating to laboratory claim integrity programs for health benefit

plans.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subtitle A, Title 8, Insurance Code, is amended

by adding Chapter 1224 to read as follows:

CHAPTER 1224. LABORATORY CLAIM INTEGRITY PROGRAMS

Sec. 1224.001. DEFINITIONS. In this chapter:

(1) "Clinical laboratory test" means the examination

of a sample of biological material taken from a human body ordered

by a physician or health care provider for use in the diagnosis,

prevention, or treatment of a disease or the identification or

assessment of a medical or physical condition.

(2) "Enrollee" means an individual enrolled in a

health benefit plan.

(3) "Health benefit plan issuer" means an entity

authorized under this code or another insurance law of this state to

provide benefits for health care services, including:

(A) an insurance company;

(B) a group hospital service corporation

operating under Chapter 842;

(C) a health maintenance organization operating

under Chapter 843;

(D) an approved nonprofit health corporation

that holds a certificate of authority under Chapter 844;

(E) a multiple employer welfare arrangement that

holds a certificate of authority under Chapter 846; or

(F) a fraternal benefit society operating under

Chapter 885.

(4) "Laboratory claim integrity program" means a claim

editing program that identifies wasteful clinical laboratory tests

based on the health benefit plan's clinical laboratory testing

reimbursement policies.

(5) "Person" means an individual, corporation, trust,

partnership, association, or any other legal entity.

Sec. 1224.002. REGISTRATION FOR PERSON PROVIDING

LABORATORY CLAIM INTEGRITY PROGRAM. (a) A person shall register

with the department before providing a laboratory claim integrity

program in this state. The registration is valid for three years and

may be renewed.

(b) The commissioner shall promulgate a form to be submitted

under this section for the initial registration and renewal of a

registration. The form for initial registration must include:

(1) the name, address, telephone number, and e-mail

address of the applicant;

(2) the name and address of an agent for service of

process in this state; and

(3) a summary of the laboratory claim integrity

program.

(c) Upon request by the commissioner, a person registered

under this section shall identify each health benefit plan issuer

who has contracted with the person for the provision of a laboratory

claim integrity program.

Sec. 1224.003. EXEMPTIONS. (a) This chapter does not

require registration as a person providing a laboratory claim

integrity program by:

(1) a health benefit plan issuer; or

(2) a utilization review agent that has been issued a

certificate of registration under Chapter 4201.

(b) The activities of a laboratory claim integrity program

are exempt from the requirements of Chapter 4201.

Sec. 1224.004. REQUIREMENTS FOR LABORATORY CLAIM INTEGRITY

PROGRAMS. (a) A laboratory claim integrity program shall:

(1) apply only objective, evidence-based, and

population-based clinical laboratory testing reimbursement

policies; and

(2) include a summary of the program or an electronic

link to a summary of the program on its public Internet website.

(b) A laboratory claim integrity program may not:

(1) require the use of clinical decision support

software by an enrollee's physician or health care provider before

the physician or provider orders a clinical laboratory test for the

enrollee;

(2) restrict, limit, or influence a clinical

laboratory test provider's choice of electronic health record

software, electronic medical record software, or practice

management software;

(3) restrict, limit, or influence a clinical

laboratory test provider's choice of third-party claim-filing

service, billing service, or electronic data interchange

clearinghouse company;

(4) disclose an enrollee's protected health

information unless the disclosure is authorized by the enrollee or

the enrollee's authorized representative or is permitted without

authorization under the Health Insurance Portability and

Accountability Act of 1996 (42 U.S.C. Section 1320d et seq.) or

under Section 602.053; or

(5) hold a delegation from a health benefit plan

issuer to make claim determinations.

Sec. 1224.005. PROGRAM ACTIONS NOT ADVERSE DETERMINATION.

A denial or reduction in payment of a claim that is identified by a

laboratory claim integrity program as not meeting the requirements

of an applicable health benefit plan clinical laboratory testing

reimbursement policy is not an adverse determination for purposes

of Chapter 4201.

SECTION 2. Chapter 1224, Insurance Code, as added by this

Act, applies only to a laboratory claim integrity program contract

that is entered into or renewed on or after January 1, 2026.

SECTION 3. This Act takes effect September 1, 2025.