SECTION 260.75. Utilization Review of an IPC by HHSC

(a) HHSC conducts a utilization review of an IPC to determine if:

(1) the cost of the IPC meets the criteria described in §260.51(a)(4) of this subchapter (relating to Eligibility Criteria for DBMD Program Services and CFC Services); and

(2) the DBMD Program services and CFC services specified in the IPC meet the requirements described in §260.67(a)(1) and (b) of this subchapter (relating to Development of a Proposed Enrollment IPC).

(b) If requested by HHSC, a program provider must submit documentation supporting an IPC to HHSC no later than 10 business days after the date of HHSC's request.

(c) If HHSC determines that an IPC does not meet the criteria described in §260.51(a)(4) of this subchapter, HHSC notifies the program provider of such determination and sends written notice to the individual or LAR that the individual's DBMD Program services and CFC services are proposed for termination and includes in the notice the individual's right to request a fair hearing in accordance with §260.111 of this subchapter (relating to Individual's Right to a Fair Hearing).

(d) If HHSC determines that an IPC meets the criteria described in §260.51(a)(4) of this subchapter but one or more DBMD Program services or CFC services specified in the IPC do not meet the requirements described in §260.67(a)(1) and (b) of this subchapter, HHSC:

(1) denies or reduces the service, as appropriate;

(2) modifies and approves the IPC; and

(3) notifies the program provider, in writing, of the action taken.

(e) If HHSC notifies a program provider of the denial or reduction of a DBMD Program service or CFC service, and of the modification of the IPC in accordance with subsection (d) of this section, the program provider must send the individual or LAR written notice and provide services in accordance with:

(1) §260.83(b)(2) and (3) of this subchapter (relating to Denial of Request for Enrollment in the DBMD Program or of a DBMD Program Service or a CFC Service); or

(2) §260.87(b) and (c) of this subchapter (relating to Reduction of a DBMD Program Service or a CFC Service).

Source Note: The provisions of this §260.75 adopted to be effective February 26, 2023, 48 TexReg 896