SECTION 352.11. Provider Enrollment Determinations

(a) HHSC or its designee, in its sole discretion, approves, conditionally approves, or denies each enrollment application submitted in accordance with the requirements of this chapter. HHSC or its designee provides notice of the enrollment determination to the applicant or re-enrolling provider.

(1) Approval. If an enrollment application is approved, the approval is for a time-limited period of participation as specified in the provider agreement or notice of the enrollment determination.

(2) Conditional approval. An enrollment application may be approved with conditions as specified in the notice of the enrollment determination.

(3) Denial. If an enrollment application is denied, HHSC will provide notice of the enrollment determination by certified mail to the address of record on the enrollment application. The reason or reasons for denial are specified in the notice.

(b) In rendering the enrollment determination, HHSC or its designee will consider the following:

(1) the applicant's or re-enrolling provider's compliance with the requirements of this chapter;

(2) the applicant's or re-enrolling provider's current or previous participation in Medicaid and CHIP;

(3) whether access to care is sufficient; and

(4) the recommendation of HHSC's Office of Inspector General made pursuant to Chapter 371 of this title (relating to Medicaid and Other Health and Human Services Fraud and Abuse Program Integrity).

(c) HHSC or its designee may deny an enrollment application for:

(1) failure to meet the requirements of participation for the category of service provided;

(2) failure to repay an overpayment;

(3) termination from participation in the Medicare program;

(4) exclusion from participation in Medicaid or CHIP;

(5) failure to comply with Chapter 371 of this title;

(6) failure to provide true and accurate information during the enrollment process;

(7) failure to cooperate with required unscheduled and unannounced pre- and post-enrollment site visits; or

(8) other reasons as determined by HHSC in its sole discretion.

(d) If an enrollment application is denied, the applicant or re-enrolling provider may request that the determination be reviewed by:

(1) HHSC OIG, if the reason for denial is based on subsection (b)(4) of this section pursuant to §371.1015(c) of this title (relating to Types of Provider Enrollment Recommendations) and follow the process outlined in §371.1011 of this title (relating to Recommendation Criteria); or

(2) HHSC or its designee, if the denial is based on any other reason, as follows:

(A) The applicant or re-enrolling provider must submit a request for an informal desk review within 30 calendar days from the date of the notice.

(B) The request for an informal desk review must be made in writing, state the basis for disagreement, and describe any mitigating circumstances that would support a reconsideration of the enrollment determination.

(C) Upon conclusion of the resulting informal desk review, HHSC or its designee will send a written notice of the final enrollment determination to the address of record on the enrollment application.

(D) The final enrollment determination is not subject to further administrative review or reconsideration.

Source Note: The provisions of this §352.11 adopted to be effective December 31, 2012, 37 TexReg 9899