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TITLE 25HEALTH SERVICES
PART 1DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 37MATERNAL AND INFANT HEALTH SERVICES
SUBCHAPTER FHEMOPHILIA ASSISTANCE PROGRAM
RULE §37.119Right of Appeal

(a) Administrative Review.

  (1) When the program modifies, suspends, denies, or terminates eligibility or benefits, the program shall give written notice of and the reason(s) for the action. Applicants, clients, providers, or legally authorized representatives, have the right to request an administrative review of the action within 30 days of the notice date.

  (2) If the program denies a prior authorization request for program services, the program will give the client, provider, or a legally authorized representative, written notice of the denial and the right of the client, provider, or legally authorized representative, to request an administrative review of the denial within 30 days of the notice date.

  (3) If the program receives a written request for administrative review within 30 days of the notice date, the program will conduct an administrative review of the circumstances surrounding the proposed action. Within 30 days following receipt of a request for administrative review, the program will send the applicant, client, provider, or legally authorized representative, written notice of:

    (A) the program decision, including the supporting reason(s) for the decision; or

    (B) the need for extended time to research the circumstance(s), including an expected date for response to the request.

  (4) If the program does not receive a written request for administrative review within 30 days of the date of the notification, the applicant, client, provider, or legally authorized representative, is presumed to have waived the administrative review as well as access to a fair hearing, and the program's action is final.

  (5) A client, provider, or legally authorized representative, may not request administrative review of the program's denial of a prior authorization request for program services or reduced provider reimbursement amounts that are authorized by §37.114(f) of this title (relating to Benefits and Limitations).

  (6) A client, provider, or legally authorized representative, may not request an administrative review of prior authorization decisions and reimbursement amounts for claims that are paid in accordance with the reimbursement rate as defined in §37.112(33) of this title (relating to Definitions).

(b) Fair Hearing.

  (1) If the applicant, client, provider, or a legally authorized representative is dissatisfied with the program's decision and supporting reason(s) following the administrative review, the applicant, client, provider, or a legally authorized representative may request a fair hearing in writing addressed to the Hemophilia Assistance Program, Purchased Health Services Unit, Mail Code 1938, Department of State Health Services, P.O. Box 149347, Austin, Texas 78714-9347, within 20 days of receipt of the administrative review decision notice.

  (2) A fair hearing requested by an applicant, client, provider, or a legally authorized representative will be conducted in accordance with §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).

  (3) If the applicant, client, provider, or a legally authorized representative fails to request a fair hearing within the 20-day period, the applicant, client, provider, or a legally authorized representative is presumed to have waived the request for a fair hearing, and the program may take final action.


Source Note: The provisions of this §37.119 adopted to be effective April 16, 2015, 40 TexReg 2090

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