SECTION 87.215. Research and Communication with HHS Programs, Health Care Providers, and Medicaid Managed Care Organizations

(a) OMCAT staff review all available information about a consumer through inquiry into HHS program systems before referring a contact to HHS staff or MCO staff for review.

(b) OMCAT staff may contact a consumer's health care provider as part of their work on a contact.

(c) Each complaint is investigated to determine if HHS policy was followed by HHS staff and vendors contracted to provide services, including MCO staff. Applicable policies include federal and state law, administrative rules, the MCO's contract with HHSC, and internal program policies and procedures.

(d) When OMCAT research through available systems is not sufficient to address a concern or determine whether a complaint can be substantiated, OMCAT staff request a response to the complaint from appropriate HHS or MCO staff. OMCAT staff may also contact the consumer's health care provider directly in order to resolve a complaint.

(e) HHS or MCO staff are asked to respond to an OMCAT request. If no response is received, a second communication is made, and documented in the HEART system. If still no response is received, the request is escalated to leadership within the HHSC Medicaid program.

(f) Upon receipt of information from HHS or MCO staff, OMCAT staff review to determine if the concern has been addressed and if OMCAT staff can determine whether the complaint can be substantiated. If the response is found to be inadequate by OMCAT staff or if additional information is required, OMCAT staff refer the contact back to HHS or MCO staff for additional review.

(g) OMCAT staff seek assistance from HHSC Medicaid program staff on some contacts, including complaints that raise questions about policy or contract compliance.

Source Note: The provisions of this §87.215 adopted to be effective January 10, 2019, 44 TexReg 252; amended to be effective December 21, 2022, 47 TexReg 8273