Tex. Gov't Code Section 532.0404
External Medical Review


(a)

In this section, “external medical reviewer” means 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 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 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)

the commission’s denial of eligibility for a Medicaid program in which eligibility is based on a 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:

(1)

a common procedure for external medical reviews that:

(A)

to the greatest extent possible, reduces:
(i)
administrative burdens on providers; and
(ii)
the submission of duplicative information or documents; and

(B)

bases a medical necessity determination on clinical criteria that is:
(i)
publicly available;
(ii)
current;
(iii)
evidence-based; and
(iv)
peer-reviewed; and

(2)

a procedure and time frame for expedited reviews that allow the external medical reviewer to:

(A)

identify an appeal that requires an expedited resolution; and

(B)

resolve the review of the appeal within a specified period.

(f)

The external medical reviewer shall conduct an external medical review within a period the commission specifies.

(g)

A recipient or Medicaid 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):

(A)

occurs after the internal Medicaid managed care organization appeal and before the Medicaid fair hearing; and

(B)

is granted when a 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.

(h)

The external medical reviewer’s determination of medical necessity establishes the minimum level of services a recipient must receive, except that the level of services may not exceed the level identified as medically necessary by the ordering health care provider.

(i)

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.

(j)

To the extent money is appropriated for this purpose, the commission shall publish data regarding prior authorizations the external medical reviewer reviewed, including the rate of prior authorization denials the external medical reviewer overturned and additional information the commission and the external medical reviewer determine appropriate.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.

Source: Section 532.0404 — External Medical Review, https://statutes.­capitol.­texas.­gov/Docs/GV/htm/GV.­532.­htm#532.­0404 (accessed Jun. 5, 2024).

532.0001
Definition
532.0051
Commission Administration of Medicaid
532.0052
Streamlining Administrative Processes
532.0053
Grievances
532.0054
Office of Community Access and Services
532.0055
Service Delivery Audit Mechanisms
532.0056
Federal Authorization for Reform
532.0057
Fees, Charges, and Rates
532.0058
Acute Care Billing Coordination System
532.0059
Recovery of Certain Third-party Reimbursements
532.0060
Dental Director
532.0061
Alignment of Medicaid and Medicare Diabetic Equipment and Supplies Written Order Procedures
532.0101
Financing Optimization
532.0102
Retention of Certain Money to Administer Certain Programs
532.0103
Biennial Financial Report
532.0151
Streamlining Provider Enrollment and Credentialing Processes
532.0152
Use of National Provider Identifier Number
532.0153
Enrollment of Certain Eye Health Care Providers
532.0154
Rural Health Clinic Reimbursement
532.0155
Rural Hospital Reimbursement
532.0156
Reimbursement System for Electronic Health Information Review and Transmission
532.0201
Data Collection System
532.0202
Information Collection and Analysis
532.0203
Public Access to Certain Data
532.0204
Data Regarding Treatment for Prenatal Alcohol or Controlled Substance Exposure
532.0205
Medical Technology
532.0206
Pilot Projects Relating to Technology Applications
532.0251
Definition
532.0252
Implementation of Certain Provisions
532.0253
Electronic Visit Verification System Implementation
532.0254
Information to Be Verified
532.0255
Compliance Standards and Standardized Processes
532.0256
Recipient Compliance
532.0257
Health Care Provider Compliance
532.0258
Health Care Provider: Use of Proprietary System
532.0259
Stakeholder Input
532.0260
Rules
532.0301
Bill of Rights and Bill of Responsibilities
532.0302
Uniform Fair Hearing Rules
532.0303
Support and Information Services for Recipients
532.0304
Nursing Services Assessments
532.0305
Therapy Services Assessments
532.0306
Wellness Screening Program
532.0307
Federally Qualified Health Center and Rural Health Clinic Services
532.0351
Tailored Benefit Packages for Certain Categories of Medicaid Population
532.0352
Waiver Program for Certain Individuals with Chronic Health Conditions
532.0353
Buy-in Programs for Certain Individuals with Disabilities
532.0401
Review of Prior Authorization and Utilization Review Processes
532.0402
Accessibility of Information Regarding Prior Authorization Requirements
532.0403
Notice Requirements Regarding Coverage or Prior Authorization Denial and Incomplete Requests
532.0404
External Medical Review
532.0451
Hospital Emergency Room Use Reduction Initiatives
532.0452
Physician Incentive Program to Reduce Hospital Emergency Room Use for Non-emergent Conditions
532.0453
Continued Implementation of Certain Interventions and Best Practices by Providers
532.0454
Health Savings Account Pilot Program
532.0455
Durable Medical Equipment Reuse Program

Accessed:
Jun. 5, 2024

§ 532.0404’s source at texas​.gov