Specifications include, but are not limited to: Conduct external medical reviews (EMRs) for: 1) Texas Medicaid managed care organization (MCO) or dental maintenance organization (DMO) benefit denials or reductions that are appealed by Medicaid members or their authorized representatives and subsequently are requested for review by a contracted IRO; and 2) eligibility decisions made by HHSC for a Medicaid program in which eligibility is based on a Medicaid applicant or recipient's medical or functional need. Initially, a contracted IRO will be responsible for reviewing eligibility decisions related to the denial of medical necessity Medically Dependent Children Program (MDCP) and STAR+PLUS Home and Community Based Services (HCBS) program.
