Section 540.0267 - [Effective 4/1/2025] 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. (Gov. Code, Secs. 533.005(a)(15), (19).)Tex. Gov't. Code § 540.0267
Added by Acts 2023, Texas Acts of the 88th Leg.- Regular Session, ch. 769,Sec. 1.01, eff. 4/1/2025.