Section 533.00282 - [Repealed Effective 4/1/2025] Utilization Review and Prior Authorization Procedures(a) Section 4201.304(a)(2), Insurance Code, does not apply to a Medicaid managed care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, 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.Tex. Gov't. Code § 533.00282
Repealed by Acts 2023, Texas Acts of the 88th Leg.- Regular Session, ch. 769,Sec. 3.01, eff. 4/1/2025.Added by Acts 2019, Texas Acts of the 86th Leg.- Regular Session,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. 6, eff. 9/1/2019.