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.