By: Paul H.B. No. 4549       A BILL TO BE ENTITLED   AN ACT   relating to the prompt payment of health insurance claims.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Section 843.338, Insurance Code, is amended to   read as follows:          Sec. 843.338.  DEADLINE FOR ACTION ON CLEAN CLAIMS. Except   as provided by Sections 843.3385, 843.3405, and 843.339, not later   than the 45th day after the date on which a health maintenance   organization receives a clean claim from a participating physician   or provider in a nonelectronic format or the 30th day after the date   the health maintenance organization receives a clean claim from a   participating physician or provider that is electronically   submitted, the health maintenance organization shall make a   determination of whether the claim is payable and:                (1)  if the health maintenance organization determines   the entire claim is payable, pay the total amount of the claim in   accordance with the contract between the physician or provider and   the health maintenance organization;                (2)  if the health maintenance organization determines   a portion of the claim is payable, pay the portion of the claim that   is not in dispute and notify the physician or provider in writing   why the remaining portion of the claim will not be paid; or                (3)  if the health maintenance organization determines   that the claim is not payable, notify the physician or provider in   writing why the claim will not be paid.          SECTION 2.  Section 843.3405, is amended to read as follows:          Sec. 843.3405.  INVESTIGATION AND DETERMINATION OF PAYMENT.   (a)  Except as provided by Subsection (b), the [The] investigation   and determination of payment, including any coordination of other   payments, does not extend the period for determining whether a   claim is payable under Section 843.338 or 843.339 or for auditing a   claim under Section 843.340.          (b)  An investigation and determination of payment shall   extend the period for determining whether a claim is payable or for   auditing a claim if:                (1)  the health maintenance organization suspects that   the claim was submitted fraudulently or based on a   misrepresentation; and                (2)  the investigation and determination are made in   good faith.          SECTION 3.  Section 843.3385(e), Insurance Code, is amended   to read as follows:          (e)  If a health maintenance organization requests an   attachment or other information from a person other than the   participating physician or provider who submitted the claim, the   health maintenance organization, not later than the 30th calendar   day after the insurer receives a clean claim, shall provide notice   containing the name of the physician or provider from whom the   health maintenance organization is requesting information to the   physician or provider who submitted the claim.  A health   maintenance organization that requests an attachment under this   subsection shall determine whether the claim is payable on or   before the later of the 15th day after the date the insurer receives   the requested attachment or the latest date for determining whether   the claim is payable under Section 1301.103 or 1301.104. [The   health maintenance organization may not withhold payment pending   receipt of an attachment or information requested under this   subsection.  If on receiving an attachment or information requested   under this subsection the health maintenance organization   determines that there was an error in payment of the claim, the   health maintenance organization may recover any overpayment under   Section 843.350.]          SECTION 4.  Section 843.343, Insurance Code, is amended to   read as follows:          Sec. 843.343.  ATTORNEY'S FEES.  A physician or provider may   recover reasonable attorney's fees and court costs in an action to   recover payment under this subchapter only when a health   maintenance organization has acted in bad faith in making the   payment determination.          SECTION 5.  Section 843.350, Insurance Code, is amended by   amending Subsection (a) and adding Subsection (c) to read as   follows:          (a)  Except as provided by Subsection (c), a [A] health   maintenance organization may recover an overpayment to a physician   or provider if:                (1)  not later than the one year [the 180th day] after   the date the physician or provider receives the payment, the health   maintenance organization provides written notice of the   overpayment to the physician or provider that includes the basis   and specific reasons for the request for recovery of funds; and                (2)  the physician or provider does not make   arrangements for repayment of the requested funds on or before the   45th day after the date the physician or provider receives the   notice.          (c)  A health maintenance organization may recover an   overpayment to a physician or health care provider at any time if   the claim was submitted fraudulently or based on a   misrepresentation.          SECTION 6.  Section 843.342, Insurance Code, is amended by   amending Subsections (h) and (n) to read as follows:          (h)  A health maintenance organization is not liable for a   penalty under this section:                (1)  if the failure to pay the claim in accordance with   this subchapter is a result of a catastrophic event and:                      (A)  the commissioner published a notice allowing   an extension of the applicable prompt payment deadlines due to the   catastrophic event; or                      (B)  the department approved the health   maintenance organization's request for an extension due to the   substantial interference of the catastrophic event with the normal   business operations of the health maintenance organization; or                (2)  if the claim was not paid or paid in accordance   with this subchapter, but for less than the contracted rate, and:                      (A)  the physician or provider notifies the health   maintenance organization of the underpayment after the 270th day   after the date the underpayment was received; and                      (B)  the health maintenance organization pays the   balance of the claim on or before the 30th day after the date the   health maintenance organization receives the notice.          (n)  In this section:                (1)  "Institutional [, "institutional] provider" means   a hospital or other medical or health-related service facility that   provides care for the sick or injured or other care that may be   covered in an evidence of coverage; and                (2)  "Billed charges" means the lowest rate the   preferred provider will accept directly from a patient as payment   in full for the services.          SECTION 7.  Section 1301.103, Insurance Code, is amended to   read as follows:          Sec. 1301.103.  DEADLINE FOR ACTION ON CLEAN CLAIMS. Except   as provided by Sections 1301.104, 1301.1053, and 1301.1054, not   later than the 45th day after the date an insurer receives a clean   claim from a preferred provider in a nonelectronic format or the   30th day after the date an insurer receives a clean claim from a   preferred provider that is electronically submitted, the insurer   shall make a determination of whether the claim is payable and:                (1)  if the insurer determines the entire claim is   payable, pay the total amount of the claim in accordance with the   contract between the preferred provider and the insurer;                (2)  if the insurer determines a portion of the claim is   payable, pay the portion of the claim that is not in dispute and   notify the preferred provider in writing why the remaining portion   of the claim will not be paid; or                (3)  if the insurer determines that the claim is not   payable, notify the preferred provider in writing why the claim   will not be paid.          SECTION 8.  Section 1301.1053, Insurance Code, is amended to   read as follows:          Sec. 1301.1053.  DEADLINES NOT EXTENDED. (a)  Except as   provided by Subsection (b), the [The] investigation and   determination of payment, including any coordination of other   payments, does not extend the period for determining whether a   claim is payable under Section 1301.103 or 1301.104 or for auditing   a claim under Section 1301.105.          (b)  An investigation and determination of payment shall   extend the period for determining whether a claim is payable or for   auditing a claim if:                (1)  the insurer suspects that the claim was submitted   fraudulently or based on a misrepresentation; and                (2)  the investigation and determination are made in   good faith.          SECTION 9.  Section 1301.1054(d), Insurance Code, is amended   to read as follows:          (d)  If an insurer requests an attachment or other   information from a person other than the preferred provider who   submitted the claim, the insurer, not later than the 30th calendar   day after the insurer receives a clean claim, shall provide notice   containing the name of the physician or health care provider from   whom the insurer is requesting information to the preferred   provider who submitted the claim.  An insurer that requests an   attachment under this subsection shall determine whether the claim   is payable on or before the later of the 15th day after the date the   insurer receives the requested attachment or the latest date for   determining whether the claim is payable under Section 1301.103 or   1301.104. [The insurer may not withhold payment pending receipt of   an attachment or information requested under this subsection.  If   on receiving an attachment or information requested under this   subsection the insurer determines that there was an error in   payment of the claim, the insurer may recover any overpayment under   Section 1301.132.]          SECTION 10.  Section 1301.108, Insurance Code, is amended to   read as follows:          Sec. 1301.108.  ATTORNEY'S FEES.  A preferred provider may   recover reasonable attorney's fees and court costs in an action to   recover payment under this subchapter only when an insurer has   acted in bad faith in making the payment determination.          SECTION 11.  Section 1301.132, Insurance Code, is amended by   amending Subsection (a) and adding Subsection (c) to read as   follows:          (a)  Except as provided by Subsection (c), an [An] insurer   may recover an overpayment to a physician or health care provider   if:                (1)  not later than one year [the 180th day] after the   date the physician or provider receives the payment, the insurer   provides written notice of the overpayment to the physician or   provider that includes the basis and specific reasons for the   request for recovery of funds; and                (2)  the physician or provider does not make   arrangements for repayment of the requested funds on or before the   45th day after the date the physician or provider receives the   notice.          (c)  An insurer may recover an overpayment to a physician or   health care provider at any time if the claim was submitted   fraudulently or based on a misrepresentation.          SECTION 12.  Section 1301.137, Insurance Code, is amended by   amending Subsection (h) and adding Subsection (m) to read as   follows:          (h)  An insurer is not liable for a penalty under this   section:                (1)  if the failure to pay the claim in accordance with   Subchapter C is a result of a catastrophic event and:                      (A)  the commissioner published a notice allowing   an extension of the applicable prompt payment deadlines due to the   catastrophic event; or                      (B)  the department approved the insurer's   request for an extension due to the substantial interference of the   catastrophic event with the normal business operations of the   insurer; or                (2)  if the claim was not paid or paid in accordance   with Subchapter C, but for less than the contracted rate, and:                      (A)  the preferred provider notifies the insurer   of the underpayment after the 270th day after the date the   underpayment was received; and                      (B)  the insurer pays the balance of the claim on   or before the 30th day after the date the insurer receives the   notice.          (m)  In this section, "billed charges" means the lowest rate   the preferred provider will accept directly from a patient as   payment in full for the services.          SECTION 13.  This Act takes effect immediately if it   receives a vote of two-thirds of all the members elected to each   house, as provided by Section 39, Article III, Texas Constitution.     If this Act does not receive the vote necessary for immediate   effect, this Act takes effect September 1, 2025.