26 Tex. Admin. Code § 554.2407 - Denied Medical Necessity
(a) If
the state Medicaid claims administrator determines that a Medicaid applicant or
a recipient does not meet the criteria for medical necessity described in
§
554.2401 of this subchapter
(relating to General Qualifications for Medical Necessity Determinations), the
state Medicaid claims administrator notifies the attending physician and the
nursing facility in writing and provides them an opportunity to present
additional information about the applicant's or recipient's medical need for
nursing facility care.
(1) If the attending
physician or a nursing facility physician does not respond or contest the
findings of the state Medicaid claims administrator within 10 working days
after receipt of the written notice about the decision, the findings are
final.
(2) If the attending
physician or a nursing facility physician contests the findings of the state
Medicaid claims administrator, at least one physician with the state Medicaid
claims administrator must review the case. If the state Medicaid claims
administrator's physician determines that the applicant's or recipient's
admission or stay is not medically necessary, the determination becomes
final.
(3) The state Medicaid
claims administrator sends written notification of the final determination of
denied medical necessity to the attending physician, the nursing facility, and
the applicant or recipient (or responsible party).
(b) After an applicant receives written
notice of a determination of denied medical necessity, the applicant or
responsible party must request a fair hearing within 90 days after the date of
denied medical necessity, or the applicant loses the right to a fair
hearing.
(c) After a recipient
receives written notice of a determination of denied medical necessity, the
recipient or responsible party must request a fair hearing within 10 days after
the date of the written notice in order to have nursing facility services paid
for during the appeal.
(1) If the recipient
requests a fair hearing within 10 days after the date of the written notice and
the determination of denied medical necessity is upheld, the effective date of
the denial is 10 days after the hearing officer's written decision.
(2) If the recipient does not request a fair
hearing within 10 days after the date of the written notice, DADS makes vendor
payments to the nursing facility at the previously established RUG rate for 15
days or until the recipient is discharged, whichever occurs first.
(3) If the recipient does not request a fair
hearing within 10 days after the date of the written notice, the recipient must
request a fair hearing within 90 days after the date of denied medical
necessity, or the recipient loses the right to a fair hearing.
(d) Fair hearings are conducted by
the Texas Health and Human Services Commission (HHSC) in accordance with HHSC
rules at 1 TAC Chapter 357.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.