1 Tex. Admin. Code § 355.110 - Informal Reviews and Formal Appeals
(a) General provisions.
(1) Definitions. The following words or
terms, when used in this section, have the following meanings, unless the
context clearly indicates otherwise.
(A)
Formal appeal--An administrative hearing requested by an interested party under
subsection (d) of this section and conducted in accordance with procedures
described at §§
RSA
357.481-
RSA
357.498 of this title (relating to Hearings
Under the Administrative Procedure Act).
(B) Informal review--The informal
reexamination of an action or determination by the Texas Health and Human
Services Commission (HHSC) under this chapter requested by an interested party
and conducted in accordance with subsection (c) of this section.
(C) Interested party--An HHSC Enterprise
contracted or enrolled provider.
(2) Standing to file informal reviews or
formal appeals. Only an interested party has standing to file for an informal
review or formal appeal under this section.
(3) Subject matter of informal reviews and
formal appeals. An interested party may request an informal review or formal
appeal regarding an action or determination under §
RSA
355.102 of this title (relating to General
Principles of Allowable and Unallowable Costs), §
RSA
355.103 of this title (relating to
Specifications for Allowable and Unallowable Costs), §
RSA 355.104 of this
title (relating to Revenues), and §
RSA
355.105 of this title (relating to General
Reporting and Documentation Requirements, Methods and Procedures), or
program-specific allowable or unallowable costs, taken specifically in regard
to the interested party.
(b) Separation of informal reviews and formal
appeals from the reimbursement determination process.
(1) The filing of a request for an informal
review or formal appeal under this section does not stay or delay
implementation of reimbursement adopted by HHSC in accordance with the
requirements of this chapter.
(2)
Closure of cost report databases used in the reimbursement determination
process and application of results of pending review or appeal. To facilitate
the timely and efficient calculation of reimbursement amounts, HHSC closes cost
report databases used in the reimbursement determination process prior to the
proposal of reimbursement amounts.
(A) Impact
on database of pending informal review or formal appeal. If an informal review
is pending at the time the database is closed, the database shall include the
interested party's cost report data including any adjustments made either in
the desk review or field audit. If a formal appeal is pending at the time the
database is closed, the database shall include the interested party's cost
report data including any adjustments required as a result of the informal
review.
(B) Uniform reimbursement.
(i) For programs where reimbursement is
uniform by class of service and/or provider type, the cost report database used
in reimbursement determination is closed six weeks prior to the public hearing
on the proposed reimbursement that is based on the cost report
database.
(ii) If an informal
review or formal appeal is pending at the time the cost report database is
closed, the results of the informal review or formal appeal shall be applied
during the next reimbursement determination cycle, if applicable.
(C) Contractor-specific
reimbursement.
(i) For programs where
reimbursement is contractor-specific the cost report database is closed ten
weeks prior to the end of the reimbursement determination cycle.
(ii) If an informal review or formal appeal
is pending at the time the cost report database is closed, the results of the
informal review or formal appeal shall be applied to the interested party's
payment retroactively to the beginning of the current reimbursement
determination cycle. The results of the informal review or formal appeal shall
not be applied to the cost report database as a whole or to any other
reimbursement amounts influenced by the cost report database as a whole until
the next reimbursement determination cycle, if applicable.
(c) Informal review.
(1) An interested party who disputes an
action or determination under this chapter may request an informal review under
this section. The purpose of an informal review is to provide for the informal
and efficient resolution of the matters in dispute. An informal review is not a
formal administrative hearing, but is a prerequisite to obtaining a formal
administrative hearing and is conducted according to the following procedures:
(A) HHSC Rate Analysis must receive a written
request for an informal review by hand delivery, United States (U.S.) mail, or
special mail delivery no later than 30 calendar days from the date on the
written notification of the adjustments. If the 30th calendar day is a weekend
day, national holiday, or state holiday, then the first business day following
the 30th calendar day is the final day the receipt of the written request will
be accepted. HHSC Rate Analysis will extend this deadline if it receives a
written request for the extension by hand delivery, U.S. mail, or special mail
delivery no later than 30 calendar days from the date of the written notice of
adjustments. The extension gives the requester a total of 45 calendar days from
the date of the written notice of adjustment to file a request for an informal
review. If the 45th calendar day is a weekend day, national holiday, or state
holiday, then the 45th day is considered the next business day following the
45th calendar day. A request for an informal review or extension that is not
received by the stated deadline will not be accepted.
(B) An interested party must, with its
request for an informal review, submit a concise statement of the specific
actions or determinations it disputes, its recommended resolution, and any
supporting documentation the interested party deems relevant to the dispute. It
is the responsibility of the interested party to render all pertinent
information at the time of its request for an informal review. A request for an
informal review that does not meet the requirements of this subparagraph will
not be accepted.
(C) The written
request for the informal review or extension must be signed by an individual
legally responsible for the conduct of the interested party, such as the sole
proprietor, a partner, a corporate officer, an association officer, a
governmental official, a limited liability company member, a person authorized
by the applicable HHSC Enterprise or Texas Medicaid and Healthcare Partnership
(TMHP) signature authority designation form for the interested party on file at
the time of the request, or a legal representative for the interested party.
The administrator or director of the facility or program is not authorized to
sign the request unless the administrator or director holds one of these
positions. A request for an informal review that is not signed by an individual
legally responsible for the conduct of the interested party will not be
accepted.
(2) On receipt
of a request for informal review:
(A) The
lead staff member coordinates the review of the information submitted by the
interested party. Staff may request additional information from the interested
party, which must be received in writing by hand delivery, United States (U.S.)
mail, or special mail delivery by the lead staff member no later than 14
calendar days from the date the interested party receives the written request
for additional information. If the 14th calendar day is a weekend day, national
holiday, or state holiday, then the first business day following the 14th
calendar day is the final day the receipt of the additional information will be
accepted. Information received after 14 calendar days may not be used in the
informal review written decision unless the interested party receives written
approval of the lead staff member to submit the information after 14 calendar
days. A request for an extension to the 14-calendar-day due date must be
received by HHSC Rate Analysis prior to the 14th calendar day.
(B) Within 30 calendar days of the date a
written request for informal review that complies with paragraphs (1) and (2)
of this subsection is received or the date additional requested information is
due or received, whichever is later, the lead staff member will send the
interested party its written decision by certified mail, return receipt
requested. If the 30th calendar day is a weekend day, national holiday, or
state holiday, then the first business day following the 30th calendar day is
the final day by which the written decision must be sent.
(d) Administrative hearings. An
interested party who disagrees with the results of an informal review conducted
under subsection (c) of this section may file a formal appeal of the review.
The HHSC Appeals Division, Mail Code W-613, P.O. Box 149030, Austin, Texas
78714-9030, must receive the written request for a formal appeal from the
interested party within 15 calendar days after the interested party receives
the written decision as specified in subsection (c) of this section. The
written request for a formal appeal must state the basis of the appeal of the
adverse action and include a legible copy of the written decision from the
informal review referenced in subsection (c)(2)(B) of this section. The formal
appeal is limited to the issues that were considered in the informal review
process. The information from the interested party is limited to the pertinent
information considered in the informal review process. Formal appeals are
conducted in accordance with the provisions of §§
RSA
357.481-
RSA
357.498 of this title. If there is a conflict
between the applicable section of Chapter 357 of this title (relating to
Hearings) and the provisions of this chapter, the provisions of this chapter
prevail.
(e) Lack of standing for
formal appeal. Because the formal appeal is limited to issues considered in the
informal review process, an informal review request that does not comply with
subsection (c)(1)(A) - (C) of this section is not subject to further appeal
under §§
RSA
357.481-
RSA
357.498 of this title.
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.