Relating to preauthorization requirements for certain health care services and utilization review for certain health benefit plans. House Bill 3459 amends the Insurance Code to prohibit a health maintenance organization (HMO), preferred provider benefit plan insurer, or exclusive provider benefit plan insurer that uses a preauthorization process for health care services from requiring a physician or provider to obtain preauthorization for a particular service if, in the most recent six‑month evaluation period, the HMO or insurer has approved or would have approved not less than 90 percent of the preauthorization requests submitted by the physician or provider for the particular service. The bill, among other provisions, sets out a process for determining which physicians or providers qualify for a preauthorization exemption, including conditions that must be met for an exemption to be rescinded or denied and procedures for an independent review of an exemption determination. The bill’s provisions relating to the preauthorization exemption apply to the Employees Retirement System of Texas and the Teacher Retirement System of Texas but not to Medicaid or CHIP.

House Bill 3459 prohibits a denial or reduction of payment to a physician or provider based on medical necessity or appropriateness of care for a health care service for which the physician or provider has qualified for an exemption unless the physician or provider failed to substantially perform the service or knowingly and materially misrepresented the service in a request for payment with the specific intent to deceive and obtain an unlawful payment. The bill limits the purposes for which an HMO or insurer may conduct a retrospective review of a health care service subject to an exemption and sets out certain notice requirements for an HMO or insurer regarding a physician or provider who qualifies for an exemption.

House Bill 3459 also revises the requirement for a utilization review agent to provide a health care provider with an opportunity to discuss treatment with a licensed physician before the agent issues an adverse determination regarding a service ordered, requested, or provided by the health care provider by requiring the physician to be licensed in Texas and, if the health care provider is a physician, to have the same or similar specialty.