Texas § GV.540.0201 - CONTRACT ADMINISTRATION IMPROVEMENT EFFORTS

§ GV.540.0201. CONTRACT ADMINISTRATION IMPROVEMENT EFFORTS

CONTRACT ADMINISTRATION IMPROVEMENT EFFORTS. The commission shall make every effort to improve the administration of contracts with managed care organizations. To improve contract administration, the commission shall: (1) ensure that the commission has appropriate expertise and qualified staff to effectively manage contracts with managed care organizations under the Medicaid managed care program; (2) evaluate options for Medicaid payment recovery from a managed care organization if an enrolled recipient: (A) dies; (B) is incarcerated; (C) is enrolled in more than one state program; or (D) is covered by another liable third party insurer; (3) maximize Medicaid payment recovery options by contracting with private vendors to assist in recovering capitation payments, payments from other liable third parties, and other payments made to a managed care organization with respect to an enrolled recipient who leaves the managed care program; (4) decrease the administrative burdens of managed care for this state, managed care organizations, and providers in managed care networks to the extent that those changes are compatible with state law and existing Medicaid managed care contracts, including by: (A) where possible, decreasing duplicate administrative reporting and process requirements for managed care organizations and providers, such as requirements for submitting: (i) encounter data; (ii) quality reports; (iii) historically underutilized business reports; and (iv) claims payment summary reports; (B) allowing a managed care organization to provide updated address information directly to the commission for correction in the state system; (C) promoting consistency and uniformity among managed care organization policies, including policies relating to: (i) the preauthorization process; (ii) lengths of hospital stays; (iii) filing deadlines; (iv) levels of care; and (v) case management services; (D) reviewing the appropriateness of primary care case management requirements in the admission and clinical criteria process, such as requirements relating to: (i) including a separate cover sheet for all communications; (ii) submitting handwritten communications instead of electronic or typed review processes; and (iii) admitting patients listed on separate notices; and (E) providing a portal through which a provider in any managed care organization's provider network may submit acute care services and long-term services and supports claims; and (5) reserve the right to amend a managed care organization's process for resolving provider appeals of denials based on medical necessity to include an independent review process the commission establishes for final determination of these disputes. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611 ), Sec. 1.01, eff. April 1, 2025.