(a) A prospective provider who meets the criteria to
provide fee-for-service (FFS) oral health treatment services, as described
in Title 25, Part 1, §49.10 (relating to Provider Participation
Requirements to Provide FFS Oral Health Treatment Services), is eligible
to contract with the Department of State Health Services to provide
oral health treatment benefits. To apply for program participation,
a prospective provider must, after receiving information on the program
including the schedule of current fees, sign a contract with DSHS.
After the contract is properly executed, the prospective provider
will be provided written notice of approval to participate in the
FFS program and a copy of the program manual.
(b) The contract between the provider and DSHS may
be terminated without cause by either party with a 30-day written
notice. DSHS may modify, suspend, or terminate the contract of any
provider for due cause. Due cause includes but is not limited to:
(1) breach of contract;
(2) suspension or revocation of the provider's license
by the Texas State Board of Dental Examiners (TSBDE);
(3) disciplinary action(s) taken by the TSBDE;
(4) submission of false or fraudulent claims;
(5) amendment or judicial interpretation of federal
or state laws or other requirements in a way that would make it infeasible
or impossible for either party to fulfill the agreement, or if either
party is unable to agree on changes necessary for continuation of
the agreement;
(6) any violation of policies, procedures, rules, or
requirements; or
(7) any other reason authorized by rule, regulation,
statute, or contract.
(c) An administrative review and due process hearing
is available to any provider for the resolution of conflict between
DSHS and the provider.
(d) DSHS may not terminate a contract during the pendency
of a hearing. DSHS may withhold payments during the pendency of a
hearing, but DSHS must pay the withheld payments and resume contract
payments if the final determination is favorable to the provider.
(e) Subsections (c) and (d) of this section do not
apply if a contract is canceled by DSHS because of exhaustion of funds,
expires according to its terms, or is otherwise voided by law.
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