Tex.
Gov't Code Section 533.0071
Administration of Contracts
(1)
ensure that the commission has appropriate expertise and qualified staff to effectively manage contracts with managed care organizations under the Medicaid managed care program;(2)
evaluate options for Medicaid payment recovery from managed care organizations if the enrollee dies or is incarcerated or if an enrollee is enrolled in more than one state program or is covered by another liable third party insurer;(3)
maximize Medicaid payment recovery options by contracting with private vendors to assist in the recovery of capitation payments, payments from other liable third parties, and other payments made to managed care organizations with respect to enrollees who leave the managed care program;(4)
decrease the administrative burdens of managed care for the state, the managed care organizations, and the providers under managed care networks to the extent that those changes are compatible with state law and existing Medicaid managed care contracts, including decreasing those burdens by:(A)
where possible, decreasing the duplication of administrative reporting and process requirements for the managed care organizations and providers, such as requirements for the submission of encounter data, quality reports, historically underutilized business reports, and claims payment summary reports;(B)
allowing managed care organizations to provide updated address information directly to the commission for correction in the state system;(C)
promoting consistency and uniformity among managed care organization policies, including policies relating to the preauthorization process, lengths of hospital stays, filing deadlines, levels of care, and case management services;(D)
reviewing the appropriateness of primary care case management requirements in the admission and clinical criteria process, such as requirements relating to including a separate cover sheet for all communications, submitting handwritten communications instead of electronic or typed review processes, and admitting patients listed on separate notifications; and(E)
providing a portal through which providers in any managed care organization’s provider network may submit acute care services and long-term services and supports claims; and(5)
reserve the right to amend the managed care organization’s process for resolving provider appeals of denials based on medical necessity to include an independent review process established by the commission for final determination of these disputes.
Source:
Section 533.0071 — Administration of Contracts, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.533.htm#533.0071 (accessed Jun. 5, 2024).
