Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.13 - Right of Appeal

Current through Reg. 49, No. 28; July 12, 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.