Tex.
Gov't Code Section 533.00282
Utilization Review and Prior Authorization Procedures
(a)
Section 4201.304 (Time for Notice of Adverse Determination)(a)(2), Insurance Code, does not apply to a Medicaid managed care organization or a utilization review agent who conducts utilization reviews for a Medicaid managed care organization.(b)
In addition to the requirements of Section 533.005 (Required Contract Provisions), a contract between a Medicaid managed care organization and the commission must require that:(1)
before issuing an adverse determination on a prior authorization request, the organization provide the physician requesting the prior authorization with a reasonable opportunity to discuss the request with another physician who practices in the same or a similar specialty, but not necessarily the same subspecialty, and has experience in treating the same category of population as the recipient on whose behalf the request is submitted; and(2)
the organization review and issue determinations on prior authorization requests with respect to a recipient who is not hospitalized at the time of the request according to the following time frames:(A)
within three business days after receiving the request; or(B)
within the time frame and following the process established by the commission if the organization receives a request for prior authorization that does not include sufficient or adequate documentation.(c)
In consultation with the state Medicaid managed care advisory committee, the commission shall establish a process for use by a Medicaid managed care organization that receives a prior authorization request, with respect to a recipient who is not hospitalized at the time of the request, that does not include sufficient or adequate documentation. The process must provide a time frame within which a provider may submit the necessary documentation. The time frame must be longer than the time frame specified by Subsection (b)(2)(A) within which a Medicaid managed care organization must issue a determination on a prior authorization request.
Source:
Section 533.00282 — Utilization Review and Prior Authorization Procedures, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.533.htm#533.00282 (accessed Jun. 5, 2024).
