Section 533.00283. Annual Review of Prior Authorization Requirements

TX Govt Code § 533.00283 (2019) (N/A)

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Sec. 533.00283. ANNUAL REVIEW OF PRIOR AUTHORIZATION REQUIREMENTS. (a) Each Medicaid managed care organization, in consultation with the organization's provider advisory group required by contract, shall develop and implement a process to conduct an annual review of the organization's prior authorization requirements, other than a prior authorization requirement prescribed by or implemented under Section 531.073 for the vendor drug program. In conducting a review, the organization must:

(1) solicit, receive, and consider input from providers in the organization's provider network; and

(2) ensure that each prior authorization requirement is based on accurate, up-to-date, evidence-based, and peer-reviewed clinical criteria that distinguish, as appropriate, between categories, including age, of recipients for whom prior authorization requests are submitted.

(b) A Medicaid managed care organization may not impose a prior authorization requirement, other than a prior authorization requirement prescribed by or implemented under Section 531.073 for the vendor drug program, unless the organization has reviewed the requirement during the most recent annual review required under this section.

(c) The commission shall periodically review each Medicaid managed care organization to ensure the organization's compliance with this section.

Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.

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Section 533.002821. Prior Authorization Procedures for Hospitalized Recipient

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Section 533.00284. Reconsideration Following Adverse Determinations on Certain Prior Authorization Requests