Common use of Medical Director Clause in Contracts

Medical Director. (a) The MCO must have a qualified individual to serve as the Medical Director for its HHSC MCO Program(s). The Medical Director must be currently licensed in Texas under the Texas Medical Board as an M.D. or D.O. with no restrictions or other licensure limitations. The Medical Director must comply with the requirements of 28 T.A.C. §11.1606 and all applicable federal and state statutes and regulations. (b) The Medical Director, or his or her designee, must be available by telephone 24 hours a day, seven (7) days a week, for Utilization Review decisions. The Medical Director, and his/her designee, must either possess expertise with Behavioral Health Services, or ready access to such expertise to ensure timely and appropriate medical decisions for Members, including after regular business hours. (c) The Medical Director, or his or her designee, must be authorized and empowered to represent the MCO regarding clinical issues, Utilization Review and quality of care inquiries. The Medical Director, or his or her designee, must exercise independent medical judgment in all decisions relating to Medical Necessity. The MCO must ensure that its decisions relating to m Medical Necessity are not adversely influenced by fiscal management decisions. HHSC may conduct reviews of decisions relating to Medical Necessity upon reasonable notice. (d) For purposes of this section, the Medical Director’s designee must be: (1) a physician that meets the qualifications for a Medical Director, as described in subparts (a) through (c), above; or (2) for prior authorization determinations for outpatient pharmacy benefits, a Texas-licensed pharmacist working under the direction of the Medical Director, provided such delegation is included in the MCO’s TDI-approved utilization review plan. (e) The Medical Director, or his or her physician designee, must make determinations regarding Utilization Review appeals, including appeals of prior authorization denials for outpatient pharmacy benefits.

Medical Director. (a) The MCO must have a qualified individual to serve as the Medical Director for its HHSC MCO Program(s). The Medical Director must be currently licensed in Texas under by the Texas Medical Board as an M.D. or D.O. with no restrictions or other licensure limitations. The Medical Director must comply with the requirements of 28 T.A.C. §Tex. Admin. Code § 11.1606 and all applicable federal and state statutes and regulations. (b) The Medical Director, or his or her designee, must be available by telephone 24 hours a dayDay, seven (7) days Days a week, for Utilization Review decisions. The Medical Director, and his/his or her designee, must either possess expertise with Behavioral Health Services, or have ready access to such that expertise to ensure timely and appropriate medical decisions for Members, including after regular business hours. (c) The Medical Director, or his or her designee, must be authorized and empowered to represent the MCO regarding clinical issues, Utilization Review Review, and quality of care inquiries. The Medical Director, or his or her physician designee, must exercise independent medical judgment in all decisions relating to Medical Necessitymedical necessity. The MCO must ensure that its decisions relating to m Medical Necessity medical necessity are not adversely influenced by fiscal management decisions. HHSC may conduct reviews of decisions relating to Medical Necessity medical necessity upon reasonable notice. (d) For purposes of this section, the Medical Director’s designee must be: (1) be a physician that meets the qualifications for a Medical Director, as described in subparts Section 4.04 (a) through (c), above; or (2) for prior authorization determinations for outpatient pharmacy benefits, a Texas-licensed pharmacist working under the direction of the Medical Director, provided such delegation is included in the MCO’s TDI-approved utilization review plan. (e) The Medical Director, or his or her physician designee, must make requirements of this Section do not apply to Prior Authorization determinations regarding Utilization Review appeals, including appeals of prior authorization denials for outpatient pharmacy benefitsservices made by a Texas licensed pharmacist. These determinations must comply with Section 8.1.9.