Tex. Gov't Code Section 540.0267
Provider Appeals Process

(a)

A contract to which this subchapter applies must require the contracting Medicaid managed care organization to develop, implement, and maintain a system for tracking and resolving provider appeals related to claims payment. The system must include a process that requires:

(1)

a tracking mechanism to document the status and final disposition of each provider’s claims payment appeal;

(2)

contracting with physicians who are not network providers and who are of the same or related specialty as the appealing physician to resolve claims disputes that:

(A)

relate to denial on the basis of medical necessity; and

(B)

remain unresolved after a provider appeal;

(3)

the determination of the physician resolving the dispute to be binding on the organization and provider; and

(4)

the organization to allow a provider to initiate an appeal of a claim that has not been paid before the time prescribed by Section 540.0265 (Prompt Payment of Claims)(a)(1)(B).

(b)

A contract to which this subchapter applies must require the contracting Medicaid managed care organization to develop and establish a process for responding to provider appeals in the region in which the organization provides health care services.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.

Source: Section 540.0267 — Provider Appeals Process, https://statutes.­capitol.­texas.­gov/Docs/GV/htm/GV.­540.­htm#540.­0267 (accessed Jun. 5, 2024).

540.0001
Definitions 540.0051
Purpose and Implementation 540.0052
Recipient Directory 540.0053
Statewide Effort to Promote Medicaid Eligibility Maintenance 540.0054
Provider and Recipient Education Programs 540.0055
Marketing Guidelines 540.0056
Guidelines for Communications with Recipients 540.0057
Coordination of External Oversight Activities 540.0058
Information for Fraud Control 540.0059
Managed Care Clinical Improvement Program 540.0060
Complaint System Guidelines 540.0101
Fiscal Solvency Standards 540.0102
Profit Sharing 540.0103
Treatment of State Taxes in Calculating Experience Rebate or Profit Sharing 540.0151
Definitions 540.0152
Applicability and Construction of Subchapter 540.0153
Overall Strategy for Managing Audit Resources 540.0154
Performance Audit Selection Process and Follow-up 540.0155
Agreed-upon Procedures Engagements and Corrective Action Plans 540.0156
Audits of Pharmacy Benefit Managers 540.0157
Collecting Costs for Audit-related Services 540.0158
Collection Activities Related to Profit Sharing 540.0159
Using Information from External Quality Reviews 540.0160
Security of and Processing Controls over Information Technology Systems 540.0201
Contract Administration Improvement Efforts 540.0202
Public Notice of Request for Contract Applications 540.0203
Certification by Commission 540.0204
Contract Considerations Relating to Managed Care Organizations 540.0205
Contract Considerations Relating to Pharmacy Benefit Managers 540.0206
Mandatory Contracts 540.0207
Contractual Obligations Review 540.0208
Contract Implementation Plan 540.0209
Compliance and Readiness Review 540.0210
Internet Posting of Sanctions Imposed for Contractual Violations 540.0211
Performance Measures and Incentives for Value-based Contracts 540.0212
Monitoring Compliance with Behavioral Health Integration 540.0251
Applicability 540.0252
Accountability to State 540.0253
Capitation Rates 540.0254
Cost Information 540.0255
Fraud Control 540.0256
Recipient Outreach and Education 540.0257
Notice of Medicaid Certification Date 540.0258
Primary Care Provider Assignment 540.0259
Compliance with Provider Network Requirements 540.0260
Compliance with Provider Access Standards 540.0261
Provider Network Sufficiency 540.0262
Quality Monitoring Program for Health Care Services 540.0263
Out-of-network Provider Usage and Reimbursement 540.0264
Provider Reimbursement Rate Reduction 540.0265
Prompt Payment of Claims 540.0266
Reimbursement for Certain Services Provided Outside Regular Business Hours 540.0267
Provider Appeals Process 540.0268
Assistance Resolving Recipient and Provider Issues 540.0269
Use of Advanced Practice Registered Nurses and Physician Assistants 540.0270
Medical Director Availability 540.0271
Personnel Required in Certain Service Regions 540.0272
Certain Services Permitted in Lieu of Other Mental Health or Substance Use Disorder Services 540.0273
Outpatient Pharmacy Benefit Plan 540.0274
Pharmacy Benefit Plan: Rebates and Receipt of Confidential Information Prohibited 540.0275
Pharmacy Benefit Plan: Certain Pharmacy Benefits for Sex Offenders Prohibited 540.0276
Pharmacy Benefit Plan: Recipient Selection of Pharmaceutical Services Provider 540.0277
Pharmacy Benefit Plan: Pharmacy Benefit Providers 540.0278
Pharmacy Benefit Plan: Prompt Payment of Pharmacy Benefit Claims 540.0279
Pharmacy Benefit Plan: Maximum Allowable Cost Price and List for Pharmacy Benefits 540.0280
Pharmacy Benefit Plan: Pharmacy Benefits for Child Enrolled in Star Kids Managed Care Program 540.0301
Inapplicability of Certain Other Law to Medicaid Managed Care Utilization Reviews 540.0302
Prior Authorization Procedures for Hospitalized Recipient 540.0303
Prior Authorization Procedures for Nonhospitalized Recipient 540.0304
Annual Review of Prior Authorization Requirements 540.0305
Physician Consultation Before Adverse Prior Authorization Determination 540.0306
Reconsideration Following Adverse Determinations on Certain Prior Authorization Requests 540.0307
Maximum Period for Prior Authorization Decision 540.0351
Premium Payment Rate Determination 540.0352
Maximum Premium Payment Rates for Certain Programs 540.0353
Use of Encounter Data in Determining Premium Payment Rates and Other Payment Amounts 540.0401
Provider Reporting of Encounter Data 540.0402
Certifier of Encounter Data Qualifications 540.0403
Encounter Data Certification 540.0451
Medicaid Managed Care Plan Accreditation 540.0452
Medical Director Qualifications 540.0501
Recipient Enrollment in and Disenrollment from Medicaid Managed Care Plan 540.0502
Automatic Enrollment in Medicaid Managed Care Plan 540.0503
Enrollment of Certain Recipients in Same Medicaid Managed Care Plan 540.0504
Quality-based Enrollment Incentive Program for Medicaid Managed Care Organizations 540.0505
Limitations on Recipient Disenrollment from Medicaid Managed Care Plan 540.0551
Guidance Regarding Continuation of Services Under Certain Circumstances 540.0552
Coordination of Benefits 540.0601
Monitoring of Provider Networks 540.0602
Report on Out-of-network Provider Services 540.0603
Report on Commission Investigation of Provider Complaint 540.0604
Additional Reimbursement Following Provider Complaint 540.0605
Corrective Action Plan for Inadequate Network and Provider Reimbursement 540.0606
Remedies for Noncompliance with Corrective Action Plan 540.0651
Inclusion of Certain Providers in Medicaid Managed Care Organization Provider Network 540.0652
Provider Access Standards 540.0653
Penalties and Other Remedies for Failure to Comply with Provider Access Standards 540.0654
Provider Network Directories 540.0655
Provider Protection Plan 540.0656
Expedited Credentialing Process for Certain Providers 540.0657
Frequency of Provider Recredentialing 540.0658
Provider Incentives for Promoting Preventive Services 540.0659
Reimbursement Rate for Certain Services Provided by Certain Health Centers and Clinics Outside Regular Business Hours 540.0701
Acute Care Service Delivery Through Most Cost-effective Model 540.0702
Transition of Case Management for Children and Pregnant Women Program Recipients to Medicaid Managed Care Program 540.0703
Behavioral Health and Physical Health Services 540.0704
Targeted Case Management and Psychiatric Rehabilitative Services for Children, Adolescents, and Families 540.0705
Behavioral Health Services Provided Through Third Party or Subsidiary 540.0706
Psychotropic Medication Monitoring System for Certain Children 540.0707
Medication Therapy Management 540.0708
Special Disease Management 540.0709
Special Protocols for Indigent Populations 540.0710
Direct Access to Eye Health Care Services 540.0711
Delivery of Benefits Using Telecommunications or Information Technology 540.0712
Promotion and Principles of Patient-centered Medical Home 540.0713
Value-added Services 540.0751
Delivery of Acute Care Services and Long-term Services and Supports 540.0752
Delivery of Medicaid Benefits to Nursing Facility Residents 540.0753
Delivery of Basic Attendant and Habilitation Services 540.0754
Evaluation of Certain Program Services 540.0755
Utilization Review 540.0801
Trauma-informed Care Training 540.0802
Mental Health Providers 540.0803
Health Screening Requirements and Compliance with Texas Health Steps 540.0804
Health Care and Other Services for Children in Substitute Care 540.0805
Placement Change Notice and Care Coordination 540.0806
Medicaid Benefits for Certain Children Formerly in Foster Care 540.0851
Star Kids Managed Care Program 540.0852
Care Management and Care Needs Assessment 540.0855
Utilization Review of Prior Authorizations
Green check means up to date. Up to date

Accessed:
Jun. 5, 2024

§ 540.0267’s source at texas​.gov