Tex.
Gov't Code Section 532.0403
Notice Requirements Regarding Coverage or Prior Authorization Denial and Incomplete Requests
(a)
The commission shall ensure that a notice the commission or a Medicaid managed care organization sends to a recipient or Medicaid 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 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 the commission or organization sent to the provider; and(C)
an educational component that includes:(i)
a description of the recipient’s rights;(ii)
an explanation of the process related to appeals and Medicaid fair hearings; and(iii)
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 recipient on whose behalf the request was submitted. The notice 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 540.0306 (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 532.0402 (Accessibility of Information Regarding 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 532.0403 — Notice Requirements Regarding Coverage or Prior Authorization Denial and Incomplete Requests, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.532.htm#532.0403 (accessed Jun. 5, 2024).
