Tex.
Gov't Code Section 531.024162
Notice Requirements Regarding Medicaid Coverage or Prior Authorization Denial and Incomplete Requests
(a)
The commission shall ensure that notice sent by the commission or a Medicaid managed care organization to a Medicaid recipient or provider regarding the denial, partial denial, reduction, or termination of coverage or denial of prior authorization for a service includes:(1)
information required by federal and state law and applicable regulations;(2)
for the recipient:(A)
a clear and easy-to-understand explanation of the reason for the decision, including a clear explanation of the medical basis, applying the policy or accepted standard of medical practice to the recipient’s particular medical circumstances;(B)
a copy of the information sent to the provider; and(C)
an educational component that includes a description of the recipient’s rights, an explanation of the process related to appeals and Medicaid fair hearings, and a description of the role of an external medical review; and(3)
for the provider, a thorough and detailed clinical explanation of the reason for the decision, including, as applicable, information required under Subsection (b).(b)
The commission or a Medicaid managed care organization that receives from a provider a coverage or prior authorization request that contains insufficient or inadequate documentation to approve the request shall issue a notice to the provider and the Medicaid recipient on whose behalf the request was submitted. The notice issued under this subsection must:(1)
include a section specifically for the provider that contains:(A)
a clear and specific list and description of the documentation necessary for the commission or organization to make a final determination on the request;(B)
the applicable timeline, based on the requested service, for the provider to submit the documentation and a description of the reconsideration process described by Section 533.00284 (Reconsideration Following Adverse Determinations on Certain Prior Authorization Requests), if applicable; and(C)
information on the manner through which a provider may contact a Medicaid managed care organization or other entity as required by Section 531.024163 (Accessibility of Information Regarding Medicaid Prior Authorization Requirements); and(2)
be sent:(A)
to the provider:(i)
using the provider’s preferred method of communication, to the extent practicable using existing resources; and(ii)
as applicable, through an electronic notification on an Internet portal; and(B)
to the recipient using the recipient’s preferred method of communication, to the extent practicable using existing resources.
Source:
Section 531.024162 — Notice Requirements Regarding Medicaid Coverage or Prior Authorization Denial and Incomplete Requests, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.531.htm#531.024162 (accessed Jun. 5, 2024).
