SECTION 363.215. Termination, Reduction, or Denial of Authorization for Prescribed Pediatric Extended Care Center Services

(a) HHSC terminates authorization for PPECC services when:

(1) the participant is no longer eligible for THSteps-CCP;

(2) the participant no longer meets the medical necessity criteria for PPECC services;

(3) the PPECC cannot ensure the health and safety of the participant;

(4) the participant or the participant's responsible adult refuses to comply with the plan of care, and compliance is necessary to assure the health and safety of the participant;

(5) the participant changes PPECC providers, and the change of notification is submitted to HHSC in writing with a prior authorization request from the new PPECC provider; or

(6) after receiving PPECC services, the participant declines PPECC services and receives services at home. The home health agency or independent provider offering these services must submit and update all required authorization documentation.

(b) Notice to approve, reduce, or deny requested PPECC services.

(1) HHSC notifies the participant and the responsible adult in writing of the approval, reduction, or denial of PPECC services.

(2) HHSC notifies the provider in writing of the approval, reduction, or denial of PPECC services.

(3) The effective date of the service reduction or denial is 30 days after the date on the individual's notification letter.

(4) HHSC notifies the individual in writing of the process to appeal the reduction or denial of services.

(c) All participants of Medicaid-funded services have the right to appeal actions or determinations made by HHSC as described in Chapter 357, Subchapter A of this title (relating to Uniform Fair Hearing Rules).

Source Note: The provisions of this §363.215 adopted to be effective November 1, 2016, 41 TexReg 8284