Government Code § 540.0655

Sec. 540.0655. PROVIDER PROTECTION PLAN. (a) The commission shall develop and implement a provider protection plan designed to: (1) reduce administrative burdens on providers participating in a Medicaid managed care model or arrangement implemented under this chapter or Chapter 540A; and (2) ensure efficient provider enrollment and reimbursement. (b) To the greatest extent possible, the commission shall incorporate the measures in the provider protection plan into each contract between a managed care organization and the commission to provide health care services to recipients. (c) The provider protection plan must provide for: (1) a Medicaid managed care organization's prompt payment to and proper reimbursement of providers; (2) prompt and accurate claim adjudication through: (A) educating providers on properly submitting clean claims and on appeals; (B) accepting uniform forms, including HCFA Forms 1500 and UB-92 and subsequent versions of those forms, through an electronic portal; and (C) establishing standards for claims payments in accordance with a provider's contract; (3) adequate and clearly defined provider network standards that: (A) are specific to provider type, including physicians, general acute care facilities, and other provider types defined in the commission's network adequacy standards in effect on January 1, 2013; and (B) ensure choice among multiple providers to the greatest extent possible; (4) a prompt credentialing process for providers; (5) uniform efficiency standards and requirements for Medicaid managed care organizations for submitting and tracking preauthorization requests for Medicaid services; (6) establishing an electronic process, including the use of an Internet portal, through which providers in any managed care organization's provider network may: (A) submit electronic claims, prior authorization requests, claims appeals and reconsiderations, clinical data, and other documents that the organization requests for prior authorization and claims processing; and (B) obtain electronic remittance advice, explanation of benefits statements, and other standardized reports; (7) measuring Medicaid managed care organization retention rates of significant traditional providers; (8) creating a work group to review and make recommendations to the commission concerning any requirement under this subsection for which immediate implementation is not feasible at the time the plan is otherwise implemented, including the required process for submitting and accepting attachments for claims processing and prior authorization requests through an electronic process under Subdivision (6) and, for any requirement that is not implemented immediately, recommendations regarding the expected: (A) fiscal impact of implementing the requirement; and (B) timeline for implementing the requirement; and (9) any other provision the commission determines will ensure efficiency or reduce administrative burdens on providers participating in a Medicaid managed care model or arrangement. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.