| (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.
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