(a) HHSC or its designee, in its sole discretion, approves,
conditionally approves, or denies each enrollment application submitted
in accordance with the requirements of this chapter. HHSC or its designee
provides notice of the enrollment determination to the applicant or
re-enrolling provider.
(1) Approval. If an enrollment application is approved,
the approval is for a time-limited period of participation as specified
in the provider agreement or notice of the enrollment determination.
(2) Conditional approval. An enrollment application
may be approved with conditions as specified in the notice of the
enrollment determination.
(3) Denial. If an enrollment application is denied,
HHSC will provide notice of the enrollment determination by certified
mail to the address of record on the enrollment application. The reason
or reasons for denial are specified in the notice.
(b) In rendering the enrollment determination, HHSC
or its designee will consider the following:
(1) the applicant's or re-enrolling provider's compliance
with the requirements of this chapter;
(2) the applicant's or re-enrolling provider's current
or previous participation in Medicaid and CHIP;
(3) whether access to care is sufficient; and
(4) the recommendation of HHSC's Office of Inspector
General made pursuant to Chapter 371 of this title (relating to Medicaid
and Other Health and Human Services Fraud and Abuse Program Integrity).
(c) HHSC or its designee may deny an enrollment application
for:
(1) failure to meet the requirements of participation
for the category of service provided;
(2) failure to repay an overpayment;
(3) termination from participation in the Medicare
program;
(4) exclusion from participation in Medicaid or CHIP;
(5) failure to comply with Chapter 371 of this title;
(6) failure to provide true and accurate information
during the enrollment process;
(7) failure to cooperate with required unscheduled
and unannounced pre- and post-enrollment site visits; or
(8) other reasons as determined by HHSC in its sole
discretion.
(d) If an enrollment application is denied, the applicant
or re-enrolling provider may request that the determination be reviewed
by:
(1) HHSC OIG, if the reason for denial is based on
subsection (b)(4) of this section pursuant to §371.1015(c) of
this title (relating to Types of Provider Enrollment Recommendations)
and follow the process outlined in §371.1011 of this title (relating
to Recommendation Criteria); or
(2) HHSC or its designee, if the denial is based on
any other reason, as follows:
(A) The applicant or re-enrolling provider must submit
a request for an informal desk review within 30 calendar days from
the date of the notice.
(B) The request for an informal desk review must be
made in writing, state the basis for disagreement, and describe any
mitigating circumstances that would support a reconsideration of the
enrollment determination.
(C) Upon conclusion of the resulting informal desk
review, HHSC or its designee will send a written notice of the final
enrollment determination to the address of record on the enrollment
application.
(D) The final enrollment determination is not subject
to further administrative review or reconsideration.
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