(a) The OIG may make the following types of recommendations
regarding an enrollment application:
(1) Approval. If an enrollment application is recommended
for approval, the recommendation is for a time-limited period of participation
as specified in the provider agreement or notification of the enrollment
decision. The prospective provider must complete and submit the provider
agreement before enrollment is granted.
(2) Conditional approval. An enrollment application
may be recommended for conditional approval with conditions as specified
in the notification of the enrollment recommendation. The conditions
may consist of the imposition of any one or more administrative actions
or sanctions as specified in Subchapter G of this chapter (relating
to Administrative Actions and Sanctions) or in other Medicaid or CHIP
policy or rule.
(3) Denial. If an enrollment application is denied,
HHSC sends a written notice of the decision by certified mail to the
address of record on the enrollment application. The reason or reasons
for denial are as specified in the written notice. If the denial is
based upon a pending investigation, charge, or other legal proceeding,
the applicant or provider is ineligible to reapply until such investigation
or proceeding is finally resolved.
(b) If an enrollment application is denied based upon
the OIG's recommendation, an applicant may request an informal desk
review by the OIG of the recommendation within 20 business days from
the date of the notice of denial as follows.
(1) The request for an informal desk review must be
made in writing and must be submitted in accordance with the instructions
in the notice.
(2) The request should state the basis for disagreement
with the enrollment recommendation, include any documentary evidence,
and describe any mitigating circumstances that would support a reconsideration
of the initial enrollment recommendation.
(3) Upon conclusion of the resulting informal desk
review, the OIG notifies HHSC of its final recommendation. HHSC sends
a written notice of the final enrollment decision to the address of
record on the enrollment application.
(4) The final enrollment recommendation is not subject
to administrative review or reconsideration.
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Source Note: The provisions of this §371.1015 adopted to be effective December 31, 2012, 37 TexReg 10189; amended to be effective May 1, 2016, 41 TexReg 2941; amended to be effective February 12, 2017, 42 TexReg 417 |