SECTION 9.33. Notice of Adverse Action

(a) The commissioner or designee is authorized to make decisions concerning adverse action.

(b) The commissioner or designee must send a provider a notice advising the provider of any adverse action. The notice is sent by certified mail, return receipt requested, unless the department determines that a more immediate form of notice is required. The notice includes a description of the basis for the adverse action, including citation of the specific rule section(s) or portion of the provider agreement with which the provider in is noncompliance and informs the provider of the provider's right to an administrative hearing to contest the adverse action. If the adverse action proposed by the department is termination of the provider agreement, then the notice must also specify the dates that the department intends to begin withholding payment and to terminate the provider agreement in accordance with §409.35 of this title (relating to Withholding Provider Agreement Payments).

(c) The department does not have to give a notice of adverse action with each billing transaction for areas of the department that have a large volume of bills or which routinely post debit and credit entries. The department must give a provider a notice of appeal rights any time the provider informs the department in writing of the provider's dissatisfaction with a claim transaction which is an adverse action.

Source Note: The provisions of this §9.33 adopted to be effective June 13, 1995, 20 TexReg 3987; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841