SECTION 259.155. Denial of a CLASS Program Service or CFC Service

(a) HHSC denies a CLASS Program service or CFC service on an individual's IPC, based on a review described in §259.69 of this chapter (relating to HHSC's Review of a Proposed Enrollment IPC), §259.79 of this chapter (relating to Renewal and Revision of an IPC), or §259.83 of this chapter (relating to Utilization Review of an IPC by HHSC), if HHSC determines that the CLASS Program service or CFC service does not meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) and §259.65(b) of this chapter (relating to Development of an Enrollment IPC).

(b) If HHSC denies a CLASS Program service or CFC service on an individual's IPC, HHSC modifies the IPC and notifies the individual's CMA, in writing, of the denial.

(c) If a CMA receives a written notice from HHSC denying a CLASS Program service or CFC service, the CMA must:

(1) send a copy of the modified IPC to the DSA and, if the individual receives a service through the CDS option, to the FMSA;

(2) in accordance with the Community Living Assistance and Support Services Provider Manual, send written notice to the individual or LAR of the denial of the service, copying the individual's DSA and, if the individual receives a service through the CDS option, the FMSA; and

(3) include in the notice the individual's right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing).

(d) A CMA and DSA must:

(1) electronically access MESAV to determine if the information on the modified IPC is consistent with the information in MESAV;

(2) if the information on the modified IPC is inconsistent with the information in MESAV, notify HHSC of the inconsistency; and

(3) implement the modified IPC.

Source Note: The provisions of this §259.155 adopted to be effective January 30, 2023, 48 TexReg 362