| (a) HHSC conducts a utilization review of an IPC to
determine if:
(1) the cost of the IPC meets the criteria described
in §260.51(a)(4) of this subchapter (relating to Eligibility
Criteria for DBMD Program Services and CFC Services); and
(2) the DBMD Program services and CFC services specified
in the IPC meet the requirements described in §260.67(a)(1) and
(b) of this subchapter (relating to Development of a Proposed Enrollment
IPC).
(b) If requested by HHSC, a program provider must submit
documentation supporting an IPC to HHSC no later than 10 business
days after the date of HHSC's request.
(c) If HHSC determines that an IPC does not meet the
criteria described in §260.51(a)(4) of this subchapter, HHSC
notifies the program provider of such determination and sends written
notice to the individual or LAR that the individual's DBMD Program
services and CFC services are proposed for termination and includes
in the notice the individual's right to request a fair hearing in
accordance with §260.111 of this subchapter (relating to Individual's
Right to a Fair Hearing).
(d) If HHSC determines that an IPC meets the criteria
described in §260.51(a)(4) of this subchapter but one or more
DBMD Program services or CFC services specified in the IPC do not
meet the requirements described in §260.67(a)(1) and (b) of this
subchapter, HHSC:
(1) denies or reduces the service, as appropriate;
(2) modifies and approves the IPC; and
(3) notifies the program provider, in writing, of the
action taken.
(e) If HHSC notifies a program provider of the denial
or reduction of a DBMD Program service or CFC service, and of the
modification of the IPC in accordance with subsection (d) of this
section, the program provider must send the individual or LAR written
notice and provide services in accordance with:
(1) §260.83(b)(2) and (3) of this subchapter (relating
to Denial of Request for Enrollment in the DBMD Program or of a DBMD
Program Service or a CFC Service); or
(2) §260.87(b) and (c) of this subchapter (relating
to Reduction of a DBMD Program Service or a CFC Service).
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