| (a) For a contact involving a consumer receiving services
at a state hospital, an LBHA or LMHA, or the AMH program:
(1) OBH staff review all available information about
a consumer through inquiry into HHS program systems before referring
a contact to the appropriate rights protection officer, who is responsible
for receiving complaints from OBH.
(2) Each complaint is investigated to determine if
HHS policy was followed by HHS staff and vendors contracted to provide
services, including LBHA or LMHA staff. Applicable policies include
federal and state law, administrative rules, HHSC contracts, and internal
program policies and procedures.
(3) When OBH research through available systems is
not sufficient to address the concern or determine whether a complaint
can be substantiated, OBH staff request a response from the appropriate
rights protection officer, if the consumer has consented to discussion
of the contact.
(4) Upon receipt of a response from a rights protection
officer, OBH staff review to determine if the concerns have been addressed
and if OBH staff can determine whether a complaint can be substantiated.
If the response is found to be inadequate by OBH staff or if additional
information is required, OBH staff refer the contact back to the rights
protection officer for additional review.
(b) For a contact involving a consumer seeking behavioral
health services through the consumer's health plan:
(1) OBH staff refer a potential violation of Texas
Insurance Code Subchapter F of Chapter 1355, to the appropriate regulatory
or oversight agency.
(A) A referral for a consumer with private insurance,
the child health plan established under Chapter 62 of the Texas Health
and Safety Code or insurance bought through the federal Healthcare.gov
Marketplace is made to the Texas Department of Insurance.
(B) A referral for a consumer whose employer offers
a self-funded plan is made to the U.S. Department of Labor or, if
applicable, the public agency that administers the plan.
(C) A referral for a consumer with Medicaid is made
to the HHSC Medicaid & CHIP Services Department.
(D) A referral for a consumer with Medicare is made
to the U.S. Department of Health and Human Services' Medicare Ombudsman
program.
(E) A referral for a consumer with Tricare is made
to the U. S. Department of Defense's Defense Health Agency, Hearing
and Claim's Collection Division.
(2) OBH staff attempt to get a consumer to provide
a copy of the explanation of benefits or denial letter from the consumer's
health plan, which is submitted to the appropriate regulatory or oversight
agency.
(3) A contact relating to a potential parity violation
is left open until a response is received from the appropriate regulatory
or oversight agency.
(4) OBH staff also provide a consumer, the consumer's
LAR, or a health care provider information about how to file an appeal
or a complaint with the consumer's health plan.
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