Texas § GV.540.0267 - PROVIDER APPEALS PROCESS

§ GV.540.0267. PROVIDER APPEALS PROCESS

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. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611 ), Sec. 1.01, eff. April 1, 2025.