26 Tex. Admin. Code § 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).
Notes
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