Senate Bill 1207 – External Medical Reviews
In accordance with Tex. Gov’t. Code Section 531.024162, as amended by Senate Bill 1207, HHSC is required to contract with an independent review organization (IRO) to perform external medical reviews (EMR) when requested by Medicaid members for certain benefits that have been denied, reduced, or terminated by their MCO or DMO. This EMR options for members is planned for implementation in two phases:
- Phase 1 includes an EMR option for benefit denials or reductions based on medical necessity for Medicaid managed care services. The implementation date for this phase is May 1, 2022.
- Phase 2 includes an EMR option for benefit denials based on eligibility determinations. The implementation timeline for this phase is pending.
EMR Provider Training
The purpose of this training is to provide an overview to providers on the role/responsibilities for participants involved in an EMR following receipt of an Adverse Benefit Determination from an MCO or Dental Contractor.
- The link to the recorded training is below: https://attendee.gotowebinar.com/recording/4623254401546558726
- Slide Deck: EMR Provider Training – HHSC (PDF)
Contact: For additional information, please contact the Provider Relations Division at (210) 358-6294 or by email at ProviderRelations@CFHP.com