Current through Reg. 49, No. 38; September 20, 2024
(a) Administrative
review.
(1) If the program denies eligibility
to a program applicant, the program shall give the applicant written notice of
the denial and the applicant's right to request an administrative review of the
denial within 30 days of the date of the notification.
(2) If the program proposes to modify,
suspend, or terminate a client's eligibility for health care benefits (unless
such program actions are authorized by § 351.16 of this title (relating to
Procedures to Address Program Budget Alignment)), the program shall give the
client written notice of the proposed action and the client's right to request
an administrative review of the proposed action within 30 days of the date of
notification.
(3) If the program
denies a prior-authorization or authorization request for program services, the
program shall give the client and provider written notice of the denial and the
right of the client or provider to request an administrative review of the
denial within 30 days of the date of notification.
(4) A client, family, or provider may not
request administrative review of the program's denial of a prior-authorization
or authorization request for program services or reduced provider reimbursement
amounts that are authorized by § 351.16 of this title.
(5) If the program denies a provider's claim
that has been corrected and resubmitted for reconsideration according to §
351.10(1)(B)(ii) of this title (relating to Payment of Services), the program
shall give the provider written notice of the denial. The provider has the
right to request an administrative review of the denial within 30 days of the
date of notification.
(6) If the
program denies or proposes to modify, suspend, or terminate an individual
provider's participation in the program, the program shall give the provider
written notice of the proposed action and the provider's right to request an
administrative review of the proposed action within 30 days of the date of
notification.
(7) If the program
receives a written request for administrative review within 30 days of the date
of the notification, the program shall conduct an administrative review of the
circumstances surrounding the proposed action. Within 30 days following receipt
of a request for administrative review, the program shall send the applicant,
client, family, or provider written notice of:
(A) the program decision, including the
supporting reasons for the decision; or
(B) the need for extended time to research
the circumstances, including an expected date for response to the
request.
(8) If the
program does not receive a written request for administrative review within 30
days of the date of the notification, the applicant, client, family, or
provider is presumed to have waived the administrative review as well as access
to a fair hearing, and the program's action is final.
(b) Fair hearing. If the applicant, client,
family, or provider is dissatisfied with the program's decision and supporting
reasons following the administrative review, the applicant, client, family, or
provider may request a fair hearing in writing addressed to the Children with
Special Health Care Needs Services Program, Purchased Health Services Unit, MC
1938, Department of State Health Services, P.O. Box 149347, Austin, Texas
78714-9347 within 20 days of receipt of the administrative review decision
notice. If the applicant, client, family, or provider fails to request a fair
hearing within the 20-day period, the applicant, client, family, or provider is
presumed to have waived the request for a fair hearing, and the program may
take final action. A fair hearing requested by an applicant, client, family, or
provider shall be conducted in accordance with §§
1.51-
1.55 of
title 25 (relating to Fair Hearing Procedures).
