H.B. No. 3812 amends the Texas Insurance Code to modify preauthorization requirements for health benefit plans and the utilization review process directed by physicians. The bill stipulates that a utilization review agent must conduct reviews under the direction of a licensed physician, who cannot hold a license to practice administrative medicine. It also establishes that health maintenance organizations (HMOs) or insurers cannot require preauthorization for specific health care services if, during the most recent one-year evaluation period, they approved at least 90% of requests from the physician or provider for that service, provided the service was delivered at least five times during that period. Additionally, the bill mandates that HMOs and insurers must include all preauthorization requests in their evaluations, regardless of the type of health insurance policy involved.

Further provisions include the requirement for HMOs and insurers to notify physicians or providers at least 25 days before rescinding an exemption from preauthorization requirements, and to conduct independent reviews of adverse determinations regarding preauthorization exemptions. The bill also introduces an annual reporting requirement for HMOs and insurers to document exemptions granted, rescinded, or denied, as well as the outcomes of independent reviews. The changes will take effect on September 1, 2025, and any utilization reviews conducted prior to this date will be governed by the previous law.

Statutes affected:
Introduced: Insurance Code 4201.152, Subchapter M, Chapter , Insurance Code 155.009, Insurance Code 4201.602, Insurance Code 4201.603, Insurance Code 4201.651, Insurance Code 4201.653, Insurance Code 4201.655, Insurance Code 4201.656, Insurance Code 4201.658, Insurance Code 4201.659, Occupations Code 151.002 (Occupations Code 151, Insurance Code 4201, Subchapter M, Chapter , Insurance Code 155)
House Committee Report: Insurance Code 4201.152, Insurance Code 4201.651, Insurance Code 4201.653, Insurance Code 4201.655, Insurance Code 4201.656, Insurance Code 4201.658, Insurance Code 4201.659 (Occupations Code 151, Insurance Code 4201, Subchapter M, Chapter , Insurance Code 155)
Engrossed: Insurance Code 4201.152, Insurance Code 4201.651, Insurance Code 4201.653, Insurance Code 4201.655, Insurance Code 4201.656, Insurance Code 4201.658, Insurance Code 4201.659 (Occupations Code 151, Insurance Code 4201, Subchapter M, Chapter , Insurance Code 155)
Senate Committee Report: Insurance Code 4201.152, Insurance Code 4201.651, Insurance Code 4201.653, Insurance Code 4201.655, Insurance Code 4201.656, Insurance Code 4201.658, Insurance Code 4201.659 (Occupations Code 151, Insurance Code 4201, Subchapter M, Chapter , Insurance Code 155)
Enrolled: Insurance Code 4201.152, Insurance Code 4201.651, Insurance Code 4201.653, Insurance Code 4201.655, Insurance Code 4201.656, Insurance Code 4201.658, Insurance Code 4201.659 (Occupations Code 151, Insurance Code 4201, Subchapter M, Chapter , Insurance Code 155)