Body
Revision 19-3; Effective December 2, 2019
The Health and Human Services Commission fair hearings officer:
- notifies all persons listed on Form 4800-D, Fair Hearing Request Summary, of the date, time and location of the hearing;
- prepares a final order disposing of a case through withdrawal and sends copies of this order to the appellant and Program Support Unit (PSU) upon written notification from the appellant to withdraw an appeal;
- conducts the hearing;
- uses the Texas Medicaid & Healthcare Partnership (TMHP) nurse to determine whether any new medical information introduced at the hearing meets the medical necessity (MN) criteria for nursing facility care;
- reserves the right to hold a case open after a hearing pending medical review by TMHP physicians;
- submits a written request for medical review to TMHP for all new medical information presented at a hearing in situations where the TMHP nurse determines the new medical information presented does not meet the MN criteria;
- renders a decision; and
- sends a written copy of all hearing decisions to the member/applicant, TMHP and the PSU staff within five days of making the decision.
Administrative review of any hearings officer's decision provided in the fair hearings rules must be initiated by the appellant (applicant/member). Program staff may disagree with the decision; however, the hearings officer's decision is final. Disagreements on policy or legal issues may be submitted by program staff to the regional attorney.