26 Tex. Admin. Code § 354.17 - Right of Appeal
(a) Administrative
Review.
(1) When the program modifies,
suspends, denies, or terminates eligibility or benefits, the program shall give
written notice of and the reason(s) for the action. Applicants, clients,
providers, or legally authorized representatives, have the right to request an
administrative review of the action within 30 days of the notice
date.
(2) If the program denies a
prior authorization request for program services, the program will give the
client, provider, or a legally authorized representative, written notice of the
denial and the right of the client, provider, or legally authorized
representative, to request an administrative review of the denial within 30
days of the notice date.
(3) If the
program receives a written request for administrative review within 30 days of
the notice date, 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, provider, or legally authorized representative, written notice of:
(A) the program decision, including the
supporting reason(s) for the decision; or
(B) the need for extended time to research
the circumstance(s), including an expected date for response to the
request.
(4) If the
program does not receive a written request for administrative review within 30
days of the date of the notification, the applicant, client, provider, or
legally authorized representative, is presumed to have waived the
administrative review as well as access to a fair hearing, and the program's
action is final.
(5) A client,
provider, or legally authorized representative, may not request administrative
review of the program's denial of a prior authorization request for program
services or reduced provider reimbursement amounts that are authorized by
§
354.7(f) of this
title (relating to Benefits and Limitations).
(6) A client, provider, or legally authorized
representative, may not request an administrative review of prior authorization
decisions and reimbursement amounts for claims that are paid in accordance with
the reimbursement rate as defined in §
354.3(33) of
this title (relating to Definitions).
(b) Fair Hearing.
(1) If the applicant, client, provider, or a
legally authorized representative is dissatisfied with the program's decision
and supporting reason(s) following the administrative review, the applicant,
client, provider, or a legally authorized representative may request a fair
hearing in writing addressed to the Hemophilia Assistance Program, Purchased
Health Services Unit, Mail Code 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.
(2) A fair hearing requested by an applicant,
client, provider, or a legally authorized representative will be conducted in
accordance with §§ 1.51- 1.55 of title 25 (relating to Fair Hearing
Procedures).
(3) If the applicant,
client, provider, or a legally authorized representative fails to request a
fair hearing within the 20-day period, the applicant, client, provider, or a
legally authorized representative is presumed to have waived the request for a
fair hearing, and the program may take final action.
Notes
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