Medicaid managed care organizations and similar coverage-authorizing entities must post prior authorization timelines, coverage criteria, and related contact-process information on their websites.
Sec. 532.0402. ACCESSIBILITY OF INFORMATION REGARDING PRIOR AUTHORIZATION REQUIREMENTS. (a) The executive commissioner by rule shall require each Medicaid managed care organization or other entity responsible for authorizing coverage for health care services under Medicaid to ensure that the organization or entity maintains on the organization's or entity's Internet website in an easily searchable and accessible format: (1) the applicable timelines for prior authorization requirements, including: (A) the time within which the organization or entity must make a determination on a prior authorization request; (B) a description of the notice the organization or entity provides to a provider and recipient on whose behalf the request was submitted regarding the documentation required to complete a determination on a prior authorization request; and (C) the deadline by which the organization or entity is required to submit the notice described by Paragraph (B); and (2) an accurate and current catalog of coverage criteria and prior authorization requirements, including: (A) for a prior authorization requirement first imposed on or after September 1, 2019, the effective date of the requirement; (B) a list or description of any supporting or other documentation necessary to obtain prior authorization for a specified service; and (C) the date and results of each review of a prior authorization requirement conducted under Section 540.0304, if applicable. (b) The executive commissioner by rule shall require each Medicaid managed care organization or other entity responsible for authorizing coverage for health care services under Medicaid to: (1) adopt and maintain a process for a provider or recipient to contact the organization or entity to clarify prior authorization requirements or to assist the provider in submitting a prior authorization request; and (2) ensure that the process described by Subdivision (1) is not arduous or overly burdensome to a provider or recipient. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.