Tex.
Gov't Code Section 531.024164
External Medical Review
(a)
In this section, “external medical reviewer” and “reviewer” mean a third-party medical review organization that provides objective, unbiased medical necessity determinations conducted by clinical staff with education and practice in the same or similar practice area as the procedure for which an independent determination of medical necessity is sought in accordance with applicable state law and rules.(b)
The commission shall contract with an independent external medical reviewer to conduct external medical reviews and review:(1)
the resolution of a Medicaid recipient appeal related to a reduction in or denial of services on the basis of medical necessity in the Medicaid managed care program; or(2)
a denial by the commission of eligibility for a Medicaid program in which eligibility is based on a Medicaid recipient’s medical and functional needs.(c)
A Medicaid managed care organization may not have a financial relationship with or ownership interest in the external medical reviewer with which the commission contracts.(d)
The external medical reviewer with which the commission contracts must:(1)
be overseen by a medical director who is a physician licensed in this state; and(2)
employ or be able to consult with staff with experience in providing private duty nursing services and long-term services and supports.(e)
The commission shall establish a common procedure for reviews. To the greatest extent possible, the procedure must reduce administrative burdens on providers and the submission of duplicative information or documents. Medical necessity under the procedure must be based on publicly available, up-to-date, evidence-based, and peer-reviewed clinical criteria. The reviewer shall conduct the review within a period specified by the commission. The commission shall also establish a procedure and time frame for expedited reviews that allows the reviewer to:(1)
identify an appeal that requires an expedited resolution; and(2)
resolve the review of the appeal within a specified period.(f)
A Medicaid recipient or applicant, or the recipient’s or applicant’s parent or legally authorized representative, must affirmatively request an external medical review. If requested:(1)
an external medical review described by Subsection (b)(1) occurs after the internal Medicaid managed care organization appeal and before the Medicaid fair hearing and is granted when a Medicaid recipient contests the internal appeal decision of the Medicaid managed care organization; and(2)
an external medical review described by Subsection (b)(2) occurs after the eligibility denial and before the Medicaid fair hearing.(g)
The external medical reviewer’s determination of medical necessity establishes the minimum level of services a Medicaid recipient must receive, except that the level of services may not exceed the level identified as medically necessary by the ordering health care provider.(h)
The external medical reviewer shall require a Medicaid managed care organization, in an external medical review relating to a reduction in services, to submit a detailed reason for the reduction and supporting documents.(i)
To the extent money is appropriated for this purpose, the commission shall publish data regarding prior authorizations reviewed by the external medical reviewer, including the rate of prior authorization denials overturned by the external medical reviewer and additional information the commission and the external medical reviewer determine appropriate.
Source:
Section 531.024164 — External Medical Review, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.531.htm#531.024164 (accessed Jun. 5, 2024).
