Bill > HB4585

This bill addresses the submission, payment, and audit of health service claims, primarily focusing on Medicaid managed care and child health plan programs. It introduces several key provisions that enhance transparency and fairness in claims processing. The bill requires Medicaid managed care organizations to disclose detailed contact information for claims processing, including physical addresses and telephone numbers, and mandates that they provide advance notice of any changes to these contact details. It establishes a minimum 95-day window for providers to submit claims and specifies precise timelines for claim payments based on the type of service, ranging from 10 to 45 days depending on the service category. The legislation also prohibits these organizations from delegating utilization review to artificial intelligence or computer software, ensuring human oversight of claim reviews. Additionally, the bill introduces a more robust appeals process for providers, including the option to contract with independent review organizations to resolve unresolved claim disputes. The changes will apply to new or renewed contracts from September 1, 2025, and the Health and Human Services Commission is encouraged to amend existing contracts to align with these new requirements. The bill aims to create more accountability and streamline the claims process for healthcare providers in Texas's Medicaid and child health plan programs.

Health and Social Services

https://capitol.texas.gov/BillLookup/History.aspx?LegSess=89R&Bill=HB4585