SECTION 371.1015. Types of Provider Enrollment Recommendations

(a) The OIG may make the following types of recommendations regarding an enrollment application:

(1) Approval. If an enrollment application is recommended for approval, the recommendation is for a time-limited period of participation as specified in the provider agreement or notification of the enrollment decision. The prospective provider must complete and submit the provider agreement before enrollment is granted.

(2) Conditional approval. An enrollment application may be recommended for conditional approval with conditions as specified in the notification of the enrollment recommendation. The conditions may consist of the imposition of any one or more administrative actions or sanctions as specified in Subchapter G of this chapter (relating to Administrative Actions and Sanctions) or in other Medicaid or CHIP policy or rule.

(3) Denial. If an enrollment application is denied, HHSC sends a written notice of the decision by certified mail to the address of record on the enrollment application. The reason or reasons for denial are as specified in the written notice. If the denial is based upon a pending investigation, charge, or other legal proceeding, the applicant or provider is ineligible to reapply until such investigation or proceeding is finally resolved.

(b) If an enrollment application is denied based upon the OIG's recommendation, an applicant may request an informal desk review by the OIG of the recommendation within 20 business days from the date of the notice of denial as follows.

(1) The request for an informal desk review must be made in writing and must be submitted in accordance with the instructions in the notice.

(2) The request should state the basis for disagreement with the enrollment recommendation, include any documentary evidence, and describe any mitigating circumstances that would support a reconsideration of the initial enrollment recommendation.

(3) Upon conclusion of the resulting informal desk review, the OIG notifies HHSC of its final recommendation. HHSC sends a written notice of the final enrollment decision to the address of record on the enrollment application.

(4) The final enrollment recommendation is not subject to administrative review or reconsideration.

Source Note: The provisions of this §371.1015 adopted to be effective December 31, 2012, 37 TexReg 10189; amended to be effective May 1, 2016, 41 TexReg 2941; amended to be effective February 12, 2017, 42 TexReg 417