Section 532.0403 - [Effective 4/1/2025] Notice Requirements Regarding Coverage Or Prior Authorization Denial And Incomplete Requests(a) The commission shall ensure that a notice the commission or a Medicaid managed care organization sends to a recipient or Medicaid 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 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 the commission or organization sent to the provider; and(C) an educational component that includes: (i) a description of the recipient's rights;(ii) an explanation of the process related to appeals and Medicaid fair hearings; and(iii) 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 recipient on whose behalf the request was submitted. The notice 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 540.0306, 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 532.0402; 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. (Gov. Code, Sec. 531.024162.)Tex. Gov't. Code § 532.0403
Added by Acts 2023, Texas Acts of the 88th Leg.- Regular Session, ch. 769,Sec. 1.01, eff. 4/1/2025.