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SECTION 1. Section 533.0071,
Government Code, is amended to read as follows:
Sec. 533.0071.
ADMINISTRATION OF CONTRACTS. The commission shall make every effort to
improve the administration of contracts with managed care organizations.
To improve the administration of these contracts, 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 managed care organizations if the enrollee
dies or is incarcerated or if an enrollee is enrolled in more than one
state program or is covered by another liable third party insurer;
(3) maximize Medicaid
payment recovery options by contracting with private vendors to assist in
the recovery of capitation payments, payments from other liable third
parties, and other payments made to managed care organizations with respect
to enrollees who leave the managed care program;
(4) decrease the
administrative burdens of managed care for the state, the managed care
organizations, and the providers under managed care networks to the extent
that those changes are compatible with state law and existing Medicaid
managed care contracts, including decreasing those burdens by:
(A) where possible,
decreasing the duplication of administrative reporting requirements for the
managed care organizations, such as requirements for the submission of
encounter data, quality reports, historically underutilized business
reports, and claims payment summary reports;
(B) allowing managed care
organizations 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 the [preauthorization process,] lengths of hospital
stays, filing deadlines, levels of care, and case management services;
(D) developing efficiency
standards and requirements for managed care organizations for submitting
and tracking preauthorization requests for services provided under the
Medicaid program [reviewing the appropriateness of primary care case
management requirements in the admission and clinical criteria process,
such as requirements relating to including a separate cover sheet for all
communications, submitting handwritten communications instead of electronic
or typed review processes, and admitting patients listed on separate
notifications]; [and]
(E) providing a single
portal through which providers in any managed care organization's provider
network may submit claims; [and]
(F) requiring the use of
standardized application processes and forms for credentialing providers in
a managed care organization's network; and
(G) promoting prompt
adjudication of claims through
provider education on the
proper submission of clean claims and on appeals;
(5) reserve the right to
amend the managed care organization's process for resolving provider
appeals of denials based on medical necessity to include an independent
review process established by the commission for final determination of
these disputes; and
(6) monitor and evaluate
a managed care organization's compliance with contractual requirements
regarding:
(A) the reduction of
administrative burdens for network providers; and
(B) complaints regarding
claims adjudication or payment.
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SECTION 1. Section 533.0071,
Government Code, is amended to read as follows:
Sec. 533.0071.
ADMINISTRATION OF CONTRACTS. The commission shall make every effort to
improve the administration of contracts with managed care organizations.
To improve the administration of these contracts, 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 managed care organizations if the enrollee
dies or is incarcerated or if an enrollee is enrolled in more than one
state program or is covered by another liable third party insurer;
(3) maximize Medicaid
payment recovery options by contracting with private vendors to assist in
the recovery of capitation payments, payments from other liable third
parties, and other payments made to managed care organizations with respect
to enrollees who leave the managed care program;
(4) decrease the
administrative burdens of managed care for the state, the managed care
organizations, and the providers under managed care networks to the extent
that those changes are compatible with state law and existing Medicaid
managed care contracts, including decreasing those burdens by:
(A) where possible,
decreasing the duplication of administrative reporting requirements for the
managed care organizations, such as requirements for the submission of
encounter data, quality reports, historically underutilized business
reports, and claims payment summary reports;
(B) allowing managed care
organizations 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 the [preauthorization process,] lengths of hospital
stays, filing deadlines, levels of care, and case management services;
(D) developing uniform efficiency standards and
requirements for managed care organizations for the submission and tracking
of preauthorization requests for services provided under the Medicaid
program [reviewing the appropriateness of primary care case
management requirements in the admission and clinical criteria process,
such as requirements relating to including a separate cover sheet for all
communications, submitting handwritten communications instead of electronic
or typed review processes, and admitting patients listed on separate
notifications]; [and]
(E) providing a [single] portal through which
providers in any managed care organization's provider network may:
(i) submit electronic claims, prior authorization requests, claims appeals, and
reconsiderations, clinical data, and other documentation that the managed
care organization requests for prior authorization and claims processing;
and
(ii) obtain electronic remittance advice, explanation of benefits
statements, and other standardized reports; [and]
(F) requiring the use of
standardized application processes and forms for prompt credentialing of providers in a managed care
organization's network; and
(G) promoting prompt and accurate adjudication of claims through:
(i) provider education on
the proper submission of clean claims and on appeals;
(ii) acceptance of uniform forms, including the Centers for Medicare
and Medicaid Services Forms 1500 and UB-92, through an electronic portal;
and
(iii) the establishment of standards for claims payments in accordance
with a provider's contract;
(5) reserve the right to
amend the managed care organization's process for resolving provider
appeals of denials based on medical necessity to include an independent
review process established by the commission for final determination of
these disputes;
(6) monitor and evaluate
a managed care organization's compliance with contractual requirements
regarding:
(A) the reduction of
administrative burdens for network providers; and
(B) complaints regarding
claims adjudication or payment;
(7) measure the rates of retention by managed care organizations of
significant traditional providers; and
(8) develop adequate and clearly defined provider network standards
that are specific to provider type and that ensure choice among multiple
providers to the greatest extent possible.
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