Text of section effective until April 01, 2025
Sec. 533.00282.  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.
Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.