(a) The commission shall ensure that a notice the commission or a Medicaid managed care organization sends to a recipient or Medicaid provider regarding the denial, partial denial, reduction, or termination of coverage or denial of prior authorization for a service includes:
(1) information required by federal and state law and regulations;
(2) for the recipient:
(A) a clear and easy-to-understand explanation of the reason for the decision, including a clear explanation of the medical basis, applying the policy or accepted standard of medical practice to the recipient’s particular medical circumstances;
(B) a copy of the information the commission or organization sent to the provider; and
(C) an educational component that includes:
(i) a description of the recipient’s rights;
(ii) an explanation of the process related to appeals and Medicaid fair hearings; and
(iii) a description of the role of an external medical review; and
(3) for the provider, a thorough and detailed clinical explanation of the reason for the decision, including, as applicable, information required under Subsection (b).
(b) The commission or a Medicaid managed care organization that receives from a provider a coverage or prior authorization request that contains insufficient or inadequate documentation to approve the request shall issue a notice to the provider and the recipient on whose behalf the request was submitted. The notice must:
(1) include a section specifically for the provider that contains:
(A) a clear and specific list and description of the documentation necessary for the commission or organization to make a final determination on the request;
(B) the applicable timeline, based on the requested service, for the provider to submit the documentation and a description of the reconsideration process described by § 540.0306, if applicable; and
(C) information on the manner through which a provider may contact a Medicaid managed care organization or other entity as required by § 532.0402; and
(2) be sent:
(A) to the provider:
(i) using the provider’s preferred method of communication, to the extent practicable using existing resources; and
(ii) as applicable, through an electronic notification on an Internet portal; and
(B) to the recipient using the recipient’s preferred method of communication, to the extent practicable using existing resources.

Text of section effective on April 01, 2025