Texas community resource
Medicaid Managed Care External Medical Review
Texas Health and Human Services Commission
Optional independent review of a Medicaid managed-care health plan's adverse internal appeal decision.
Information last checked:
How to get help
Follow the health plan's decision notice to request external medical review after completing the internal appeal. The request may be paired with a State Fair Hearing; the health plan submits the required case record for independent review.
Who this service helps
A Texas Medicaid managed-care member, authorized representative, or legally authorized representative who disagrees with the health plan's internal appeal decision on a qualifying adverse benefit determination.
Where this service is available
Service area: Texas Medicaid managed-care members statewide, including members residing in the Central Texas counties.
A service area describes where help is offered or who may be served. It is not necessarily the organization’s physical location.
About this service
A third-party independent review organization reviews the medical information used by the managed-care organization and may uphold, partially overturn, or overturn the internal appeal decision.
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