RECONSIDERATION FOLLOWING ADVERSE DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS

(a) In consultation with the state Medicaid managed care advisory committee, the commission shall establish a uniform process and timeline for a Medicaid managed care organization to reconsider an adverse determination on a prior authorization request that resulted solely from the submission of insufficient or inadequate documentation. In addition to the requirements of Subchapter F, a contract between a Medicaid managed care organization and the commission to which that subchapter applies must include a requirement that the organization implement the process and timeline. (b) The process and timeline must: (1) allow a provider to submit any documentation identified as insufficient or inadequate in the notice provided under Section 532.0403; (2) allow the provider requesting the prior authorization to discuss the request with another provider who: (A) practices in the same or a similar specialty, but not necessarily the same subspecialty; and (B) has experience in treating the same category of population as the recipient on whose behalf the provider submitted the request; and (3) require the Medicaid managed care organization to amend the determination on the prior authorization request as necessary, considering the additional documentation. (c) An adverse determination on a prior authorization request is considered a denial of services in an evaluation of the Medicaid managed care organization only if the determination is not amended under Subsection (b)(3) to approve the request. (d) The process and timeline for reconsidering an adverse determination on a prior authorization request under this section do not affect: (1) any related timelines, including the timeline for an internal appeal, a Medicaid fair hearing, or a review conducted by an external medical reviewer; or (2) any rights of a recipient to appeal a determination on a prior authorization request.