86R10759 LED-D
  By: Watson S.B. No. 1140
  relating to an independent medical review of certain determinations
  by the Health and Human Services Commission or a Medicaid managed
  care organization.
         SECTION 1.  Subchapter A, Chapter 533, Government Code, is
  amended by adding Section 533.00715 to read as follows:
         Sec. 533.00715.  INDEPENDENT APPEALS PROCEDURE. (a) In
  this section, "third-party arbiter" means a third-party medical
  review organization that provides objective, unbiased medical
  necessity determinations conducted by clinical staff with
  education and practice in the same or similar practice area as the
  procedure for which an independent determination of medical
  necessity is sought.
         (b)  The commission shall contract with at least three
  independent, third-party arbiters to resolve recipient appeals of
  any commission or a Medicaid managed care organization adverse
  benefit determination or reduction in or denial of health care
  services on the basis of medical necessity.
         (c)  The commission shall establish a common procedure for
  appeals. The procedure must provide that a health care service
  ordered by a health care provider is presumed medically necessary
  and the commission or Medicaid managed care organization bears the
  burden of proof to show the health care service is not medically
  necessary. The commission shall also establish a procedure for
  expedited appeals that allows a third-party arbiter to:
               (1)  identify an appeal that requires an expedited
  resolution; and
               (2)  resolve the appeal within a specified period.
         (d)  Subject to Subsection (e), the commission shall ensure
  an appeal is randomly assigned to a third-party arbiter.
         (e)  The commission shall ensure each third-party arbiter
  has the necessary medical expertise to resolve an appeal.
         (f)  A third-party arbiter shall establish and maintain an
  Internet portal through which a recipient may track the status and
  final disposition of an appeal.
         (g)  A third-party arbiter shall educate recipients and
  employees of Medicaid managed care organizations regarding appeals
  processes, options, and proper and improper denials of health care
  services on the basis of medical necessity.
         (h)  A third-party arbiter shall review aggregate denial
  data categorized by Medicaid managed care plan to identify trends
  and determine whether a Medicaid managed care organization is
  disproportionately denying prior authorization requests from a
  single provider or set of providers.
         SECTION 2.  As soon as practicable after the effective date
  of this Act, the executive commissioner of the Health and Human
  Services Commission shall adopt the rules necessary to implement
  this Act.
         SECTION 3.  If before implementing any provision of this Act
  a state agency determines that a waiver or authorization from a
  federal agency is necessary for implementation of that provision,
  the agency affected by the provision shall request the waiver or
  authorization and may delay implementing that provision until the
  waiver or authorization is granted.
         SECTION 4.  This Act takes effect September 1, 2019.