State Medicaid MCAC – Complaints, Appeals, and Fair Hearings Subcommittee

Regulatory
November 16, 2022
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1. Call to order, roll call, and introductions The meeting was convened by Karl Serrao, Chair. 2. Senate Bill 1207, 87th Texas Legislature, regular session (2021), Independent Review Organization (IRO) External Medical Review (EMR) project update As required by Senate Bill (SB) 1207, 86th Legislative Session, the commission shall contract with an independent review organization (IRO) to conduct external medical reviews. https://capitol.texas.gov/tlodocs/86R/billtext/html /SB01207F.htm . EMR Process Member receives MCO Notice of Adverse Benefit determination Member may choose to: Accept MCO decision Request an EMR and State Fair Hearing Request a State Fair Hearing only Applicable Programs include STAR; STAR+PLUS (includes HCBS services); STAR Health; STAR Kids; Dental. As of 10/31/2022 169 EMRs Received 156 Standard (92%) 11 Withdrawn 13 Expedited (8%) 154 IRO decisions have been rendered: 37 Overturned (24%) 7 Partially Overt

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