7200, External Medical Review

Revision 23-4; Effective Dec. 1, 2023

A member can ask for an External Medical Review (EMR) when they disagree with the health plan’s internal appeal decision. An EMR is an optional, extra step the member can take to get an adverse benefit determination reviewed. The EMR is conducted by a third-party Independent Review Organization (IRO) and occurs before the State Fair Hearing.

A standard EMR takes place within 15 calendar days of the request. An expedited EMR takes place within two business days of the request.

When a member requests an EMR with a  State Fair Hearing, the MCO must upload all required State Fair Hearing documentation into the Texas Health and Human Services Commission (HHSC) State Benefits Portal within the following time frames:

  • expedited EMR request – within one calendar day of receiving the EMR request from the member, the member’s authorized representative, or the member’s legally authorized representative (LAR), unless received after 3:00 p.m. CST on a Friday, or any calendar day HHSC is closed for business. If the EMR Request is received after 3:00 p.m. CST on Friday, or on a day HHSC is closed for business, the documentation must be uploaded no later than noon the following business day; or
  • standard EMR request – no later than three calendar days after receiving the EMR request from the member, the member’s authorized representative, or the member’s LAR.

Only information used to make the MCO internal appeal decision can be uploaded into the HHSC State Benefits Portal for the IRO to review. The IRO will not consider any new information submitted by the MCO or member.

The IRO will conduct the EMR and notify the MCO of the decision to uphold, partially overturn, or overturn the MCO’s internal appeal decision. The IRO can only grant or reinstate the member’s benefits up to the level identified as medically necessary by the member’s physician or as previously authorized before the adverse benefit determination. An EMR request does not change the member’s right to a State Fair Hearing. Regardless of the EMR decision, the member continues to have the right to proceed with the State Fair Hearing. The State Fair Hearing will proceed after the EMR decision unless the member withdraws their request for a State Fair Hearing.

The member may qualify for an expedited EMR with a State Fair Hearing as outlined in STAR Kids Contract, Attachment B-1, Sections and More information can be found in the Uniformed Managed Care Manual (UMCM) 3.21 (PDF) and 3.21.1 (Word).