| (1) A facility that disputes the report of findings
described in subsection (s)(4) of this section may request an informal
review under this section. The purpose of an informal review is to
provide for the informal and efficient resolution of the matters in
dispute and is conducted according to the following procedures.
(A) HHSC must receive a written request for an informal
review by United States mail, hand delivery, special mail delivery,
or fax no later than 15 days after the date on the written notification
of the report of findings described in subsection (s)(4) of this section.
If the 15th day is a Saturday, Sunday, national holiday, or state
holiday, then the first day following the 15th day is the final day
the written request will be accepted. A request for an informal review
that is not received by the stated deadline is not granted.
(B) A facility must submit a written request for an
informal review to the HHSC Trust Fund Monitoring Unit.
(C) A facility must, with its request for an informal
review:
(i) submit a concise statement of the specific findings
it disputes;
(ii) specify the procedures or rules that were not
followed;
(iii) identify the affected cases;
(iv) describe the reason the findings are being disputed;
and
(v) include supporting information and documentation
that directly demonstrates that each disputed finding is not correct.
(D) HHSC does not grant a request for an informal review
that does not meet the requirements of this subsection.
(2) Informal review process. Upon receipt of a request
for an informal review, the Trust Fund Monitoring Unit Manager coordinates
the review of the information submitted.
(A) Additional information may be requested by HHSC,
and must be received in writing no later than 15 days after the date
the facility receives the written request for additional information.
If the 15th day is a Saturday, Sunday, national holiday, or state
holiday, then the first day following the 15th day is the final day
the additional information will be accepted.
(B) HHSC sends its written decision to the facility
by certified mail, return receipt requested.
(i) If the original findings are upheld, HHSC continues
the schedule of deficiencies and requirement for corrective action.
(ii) If the original findings are reversed, HHSC issues
a corrected schedule of deficiencies with the written decision.
(iii) If the original findings are revised, HHSC issues
a revised schedule of deficiencies including any revised corrective
action.
(iv) If the original findings are upheld or revised,
the facility may request a formal hearing in accordance with subsection
(u) of this section.
(v) If the original findings are upheld or revised
and the facility does not request a formal hearing, the facility has
60 days from the date of receipt of the written decision to complete
the corrective actions. If the facility does not complete the corrective
actions by that date, HHSC may impose a vendor hold. If HHSC imposes
a vendor hold, the facility may request a formal hearing in accordance
with subsection (u)(5) of this section. If the failure to correct
is upheld, HHSC continues the vendor hold until the facility completes
the corrective action.
(u) Formal hearing.
(1) The facility must submit a written request for
a formal hearing under this section to the HHSC Appeals Division.
(2) The written request for a formal hearing must
be received within 15 days after:
(A) the date on the written notification of the report
of findings described in subsection (s)(4) of this section; or
(B) the facility receives the written decision sent
as described in subsection (t)(2)(B) of this section.
(3) A formal hearing is conducted in accordance with
Texas Administrative Code, Title 1, Chapter 357, Subchapter I (relating
to Hearings Under the Administrative Procedure Act).
(4) No later than 60 days after a final determination
is issued as a result of a formal hearing requested by a facility
under subsection (s)(8) or (t)(2)(B)(iv) of this section, the facility
must complete any corrective action required by HHSC or be subject
to a vendor hold on payments due to the facility under the provider
agreement until the facility completes corrective action. If HHSC
imposes a vendor hold, the facility may request a formal hearing in
accordance with paragraph (5) of this subsection. If the failure to
correct is upheld, HHSC continues the vendor hold until the facility
completes the corrective action.
(5) If HHSC imposes a vendor hold under subsections
(s)(7), (t)(2)(B)(v), or (u)(4) of this section, the facility may
request a formal hearing within 15 days after receiving notice of
the correction failure and the vendor hold. The formal hearing is
limited to the issue of whether the facility completed the corrective
action.
|
| Source Note: The provisions of this §554.405 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective September 1, 2003, 28 TexReg 6941; amended to be effective August 31, 2004, 29 TexReg 8140; amended to be effective November 20, 2012, 37 TexReg 9112; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
