The commission or a Medicaid managed care organization must give specific notices about coverage denials, prior authorization denials, and incomplete requests, including explanations, documentation needs, timelines, and how to contact the organization.
Sec. 532.0403. 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. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.