2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 532 - Medicaid Administration and Operation in General › Subchapter I. Utilization Review, Prior Authorization, and Coverage Processes and Determinations › Section 532.0404. External Medical Review

Text of section effective on April 01, 2025
Sec. 532.0404.  EXTERNAL MEDICAL REVIEW.  (a)  In this section, "external medical reviewer" means a third-party medical review organization that provides objective, unbiased medical necessity determinations conducted by clinical staff with education and practice in the same or similar practice area as the procedure for which an independent determination of medical necessity is sought in accordance with state law and rules.
(b)  The commission shall contract with an independent external medical reviewer to conduct external medical reviews and review:
(1)  the resolution of a recipient appeal related to a reduction in or denial of services on the basis of medical necessity in the Medicaid managed care program; or
(2)  the commission's denial of eligibility for a Medicaid program in which eligibility is based on a recipient's medical and functional needs.
(c)  A Medicaid managed care organization may not have a financial relationship with or ownership interest in the external medical reviewer with which the commission contracts.
(d)  The external medical reviewer with which the commission contracts must:
(1)  be overseen by a medical director who is a physician licensed in this state; and
(2)  employ or be able to consult with staff with experience in providing private duty nursing services and long-term services and supports.
(e)  The commission shall establish:
(1)  a common procedure for external medical reviews that:
(A)  to the greatest extent possible, reduces:
(i)  administrative burdens on providers; and
(ii)  the submission of duplicative information or documents; and
(B)  bases a medical necessity determination on clinical criteria that is:
(i)  publicly available;
(ii)  current;
(iii)  evidence-based; and
(iv)  peer-reviewed; and
(2)  a procedure and time frame for expedited reviews that allow the external medical reviewer to:
(A)  identify an appeal that requires an expedited resolution; and
(B)  resolve the review of the appeal within a specified period.
(f)  The external medical reviewer shall conduct an external medical review within a period the commission specifies.
(g)  A recipient or Medicaid applicant, or the recipient's or applicant's parent or legally authorized representative, must affirmatively request an external medical review.  If requested:
(1)  an external medical review described by Subsection (b)(1):
(A)  occurs after the internal Medicaid managed care organization appeal and before the Medicaid fair hearing; and
(B)  is granted when a recipient contests the internal appeal decision of the Medicaid managed care organization; and
(2)  an external medical review described by Subsection (b)(2) occurs after the eligibility denial and before the Medicaid fair hearing.
(h)  The external medical reviewer's determination of medical necessity establishes the minimum level of services a recipient must receive, except that the level of services may not exceed the level identified as medically necessary by the ordering health care provider.
(i)  The external medical reviewer shall require a Medicaid managed care organization, in an external medical review relating to a reduction in services, to submit a detailed reason for the reduction and supporting documents.
(j)  To the extent money is appropriated for this purpose, the commission shall publish data regarding prior authorizations the external medical reviewer reviewed, including the rate of prior authorization denials the external medical reviewer overturned and additional information the commission and the external medical reviewer determine appropriate.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.