SECTION 351.13. Right of Appeal

(a) Administrative review.

(1) If the program denies eligibility to a program applicant, the program shall give the applicant written notice of the denial and the applicant's right to request an administrative review of the denial within 30 days of the date of the notification.

(2) If the program proposes to modify, suspend, or terminate a client's eligibility for health care benefits (unless such program actions are authorized by §38.16 of this title (relating to Procedures to Address Program Budget Alignment)), the program shall give the client written notice of the proposed action and the client's right to request an administrative review of the proposed action within 30 days of the date of notification.

(3) If the program denies a prior-authorization or authorization request for program services, the program shall give the client and provider written notice of the denial and the right of the client or provider to request an administrative review of the denial within 30 days of the date of notification.

(4) A client, family, or provider may not request administrative review of the program's denial of a prior-authorization or authorization request for program services or reduced provider reimbursement amounts that are authorized by §38.16 of this title.

(5) If the program denies a provider's claim that has been corrected and resubmitted for reconsideration according to §38.10(1)(B)(ii) of this title (relating to Payment of Services), the program shall give the provider written notice of the denial. The provider has the right to request an administrative review of the denial within 30 days of the date of notification.

(6) If the program denies or proposes to modify, suspend, or terminate an individual provider's participation in the program, the program shall give the provider written notice of the proposed action and the provider's right to request an administrative review of the proposed action within 30 days of the date of notification.

(7) If the program receives a written request for administrative review within 30 days of the date of the notification, the program shall conduct an administrative review of the circumstances surrounding the proposed action. Within 30 days following receipt of a request for administrative review, the program shall send the applicant, client, family, or provider written notice of:

(A) the program decision, including the supporting reasons for the decision; or

(B) the need for extended time to research the circumstances, including an expected date for response to the request.

(8) If the program does not receive a written request for administrative review within 30 days of the date of the notification, the applicant, client, family, or provider is presumed to have waived the administrative review as well as access to a fair hearing, and the program's action is final.

(b) Fair hearing. If the applicant, client, family, or provider is dissatisfied with the program's decision and supporting reasons following the administrative review, the applicant, client, family, or provider may request a fair hearing in writing addressed to the Children with Special Health Care Needs Services Program, Purchased Health Services Unit, MC 1938, Department of State Health Services, P.O. Box 149347, Austin, Texas 78714-9347 within 20 days of receipt of the administrative review decision notice. If the applicant, client, family, or provider fails to request a fair hearing within the 20-day period, the applicant, client, family, or provider is presumed to have waived the request for a fair hearing, and the program may take final action. A fair hearing requested by an applicant, client, family, or provider shall be conducted in accordance with §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).

Source Note: The provisions of this §351.13 adopted to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982