PROVIDER APPEALS PROCESS

(a) A contract to which this subchapter applies must require the contracting Medicaid managed care organization to develop, implement, and maintain a system for tracking and resolving provider appeals related to claims payment. The system must include a process that requires: (1) a tracking mechanism to document the status and final disposition of each provider's claims payment appeal; (2) contracting with physicians who are not network providers and who are of the same or related specialty as the appealing physician to resolve claims disputes that: (A) relate to denial on the basis of medical necessity; and (B) remain unresolved after a provider appeal; (3) the determination of the physician resolving the dispute to be binding on the organization and provider; and (4) the organization to allow a provider to initiate an appeal of a claim that has not been paid before the time prescribed by Section 540.0265(a)(1)(B). (b) A contract to which this subchapter applies must require the contracting Medicaid managed care organization to develop and establish a process for responding to provider appeals in the region in which the organization provides health care services.