Section 531.024162 - [Repealed Effective 4/1/2025] Notice Requirements Regarding Medicaid Coverage or Prior Authorization Denial and Incomplete Requests(a) The commission shall ensure that notice sent by the commission or a Medicaid managed care organization to a Medicaid recipient or 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 applicable 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 sent to the provider; and(C) an educational component that includes a description of the recipient's rights, an explanation of the process related to appeals and Medicaid fair hearings, and 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 Medicaid recipient on whose behalf the request was submitted. The notice issued under this subsection 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 533.00284, 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 531.024163; 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.Tex. Gov't. Code § 531.024162
Repealed by Acts 2023, Texas Acts of the 88th Leg.- Regular Session, ch. 769,Sec. 3.01, eff. 4/1/2025.Added by Acts 2019, Texas Acts of the 86th Leg.- Regular Session, ch. 623,Sec. 3, eff. 9/1/2019.