HB 3042

relating to laboratory claim integrity programs for health benefit
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
(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:
(B)  a group hospital service corporation
(C)  a health maintenance organization operating
(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
(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
(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
(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
(2)  the name and address of an agent for service of
(3)  a summary of the laboratory claim integrity
(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
Sec. 1224.003.  EXEMPTIONS.  (a)  This chapter does not
require registration as a person providing a laboratory claim
(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
(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
(2)  restrict, limit, or influence a clinical
laboratory test provider's choice of electronic health record
software, electronic medical record software, or practice
(3)  restrict, limit, or influence a clinical
laboratory test provider's choice of third-party claim-filing
service, billing service, or electronic data interchange
(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
(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
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.