SECTION 365.11. Rights of Appeal

(a) Administrative review.

(1) If the program denies eligibility to an applicant, the program will 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 covered benefits, the program will 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 will 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) If the program denies a client's or enrolled provider's claim for benefits or services, according to §61.7 of this title (relating to Claims Submission and Payment Rates) and §61.8 of this title (relating to Claim Filing Deadlines), the program will give the client or enrolled provider written notice of the denial. The client or enrolled provider has the right to request an administrative review of the denial within 30 days of the date of notification.

(5) If the program denies or proposes to modify, suspend, or terminate a provider's participation in the program, the program will 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.

(6) The department establishes the program's reimbursement rates. Clients and providers may not request an administrative review of reimbursement amounts for claims that are paid in accordance with the reimbursement rates as described in §61.5 of this title (relating to Benefits and Limitations).

(7) A client or provider may not request administrative review of the program's decision to restrict or categorize program services or reduce provider reimbursement amounts that are authorized by §61.5(b)(10) of this title.

(8) If the program receives a written request for administrative review within 30 days of the date of the notification, the program will conduct an administrative review of the circumstances surrounding the proposed action. Within 30 days following receipt of a request for administrative review, the program will send the applicant, client, 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.

(9) If the program does not receive a written request for administrative review within 30 days of the date of the notification, the applicant, client, 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.

(1) If the applicant, client, or provider is dissatisfied with the program's decision and supporting reasons following the administrative review, the applicant, client, or provider may request a fair hearing in writing, addressed to the program, within 20 days of receipt of the administrative review decision notice.

(2) If the program receives a written request for fair hearing within 20 days of receipt of the administrative review decision notice, a fair hearing will be conducted in accordance with §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).

(A) The program may not terminate a client or enrolled provider's eligibility until a final decision is rendered under the department's fair hearings process.

(B) The program may withhold claims payment pending final decision under the department's fair hearings process.

(C) The program must release any withheld payments and reinstate participation if the final determination is in favor of the client or provider.

(D) The program must not enter into, extend, or renew an agreement with a provider until a final decision is rendered under the department's fair hearings process.

(3) If the applicant, client, or provider fails to request a fair hearing within the 20-day period, the applicant, client, or provider is presumed to have waived the request for a fair hearing, and the program may take final action.

Source Note: The provisions of this §365.11 adopted to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421