Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 365 - KIDNEY HEALTH CARE › Section 365.11 - Rights of Appeal

Current through Reg. 49, No. 28; July 12, 2024
(a) Administrative
				review.
(1) If the program denies eligibility
				to an applicant, the program will 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 covered benefits, the program
				will 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 will 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) If the program denies a client's or
				enrolled provider's claim for benefits or services, according to §
										61.7
				of this title (relating to Claims Submission and Payment Rates) and §
										61.8 of
				this title (relating to Claim Filing Deadlines), the program will give the
				client or enrolled provider written notice of the denial. The client or
				enrolled provider has the right to request an administrative review of the
				denial within 30 days of the date of notification.
(5) If the program denies or proposes to
				modify, suspend, or terminate a provider's participation in the program, the
				program will 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.
(6) The department establishes the program's
				reimbursement rates. Clients and providers may not request an administrative
				review of reimbursement amounts for claims that are paid in accordance with the
				reimbursement rates as described in §
										61.5 of
				this title (relating to Benefits and Limitations).
(7) A client or provider may not request
				administrative review of the program's decision to restrict or categorize
				program services or reduce provider reimbursement amounts that are authorized
				by §
										61.5(b)(10)
				of this title.
(8) If the program
				receives a written request for administrative review within 30 days of the date
				of the notification, the program will conduct an administrative review of the
				circumstances surrounding the proposed action. Within 30 days following receipt
				of a request for administrative review, the program will send the applicant,
				client, 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.
(9) If the
				program does not receive a written request for administrative review within 30
				days of the date of the notification, the applicant, client, 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.