(a) Denial of an Individual's Request for Enrollment.
(1) HHSC denies an individual's request for enrollment
in the DBMD Program if:
(A) the individual does not meet the eligibility criteria
described in §260.51(a) of this subchapter (relating to Eligibility
Criteria for DBMD Program Services and CFC Services);
(B) the individual or LAR fails to submit a completed
Medicaid application to HHSC within one calendar year after the date
of the case manager's initial in-person visit in the individual's
residence; or
(C) the individual cannot obtain services from at least
one program provider.
(2) HHSC sends a written notice of denial for enrollment
in the DBMD Program to the program provider that the program provider,
upon receipt, must send to the individual or LAR, copying the FMSA
if applicable.
(3) If the individual or LAR requests a fair hearing,
the program provider is not required to provide services to the individual
while the appeal is pending.
(b) Denial of a DBMD Program service or a CFC Service.
(1) HHSC denies a DBMD Program service or a CFC service
requested on the individual's IPC if HHSC determines, following utilization
review conducted as described in §260.75 of this subchapter (relating
to Utilization Review of an IPC by HHSC), that the service does not
meet the requirements described in §260.67(a)(1) and (b) of this
subchapter (relating to Development of a Proposed Enrollment IPC).
(2) HHSC sends a written notice with the effective
date of the denial to the program provider that the program provider,
upon receipt but no later than 12 calendar days before the effective
date of denial, must send to the individual or LAR, copying the FMSA,
if applicable.
(3) If the service denied by HHSC is requested:
(A) on an enrollment IPC submitted by the program provider
in accordance with §260.61 of this subchapter (relating to Process
for Enrollment of an Individual) and the individual or LAR requests
a fair hearing, the program provider is not required to provide the
service while the appeal is pending; or
(B) on a revision or renewal IPC submitted by the program
provider in accordance with §260.77 of this subchapter (relating
to Renewal and Revision of an IPP and IPC) and the individual or LAR
requests a fair hearing before the effective date of denial specified
in the written notice, the program provider:
(i) is not required to provide the service while the
appeal is pending if the service was not authorized by HHSC on the
prior IPC; or
(ii) must provide the service at the previously approved
amount or level while the appeal is pending if the service was authorized
by HHSC on the prior IPC.
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