Texas Register, Volume 34, Number 33, Pages 5445-5614, August 14, 2009 Page: 5,476
5445-5614 p. ; 28 cm.View a full description of this periodical.
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(3) failing to reimburse the department as requested for
overpayments made to the client;
(4) failing to apply for medical, drug, and transportation
benefits under Title XIX, Social Security Act (Medicaid);
(5) becoming eligible for drug, transportation, and medical
benefits under the Medicaid Program;
(6) regaining native kidney function;
(7) voluntarily discontinuing treatment for ESRD;
(8) becoming incarcerated by or in the custody of a city,
county, state, or federal entity;
(9) becoming a ward of the state;
(10) determination by the program that the client made a
material misstatement or misrepresentation on their application or any
document required to support their application;
(11) determination by the program that the client submitted
false claim(s); or
(12) lack of a claim for benefits paid by the program on
behalf of the client for a minimum period of 12 consecutive months.
(d) Any action taken under subsections (a) or (c) of this section
does not relieve the client, or the person(s) with legal obligation to
support the client, of any financial obligation owed to the program.
(e) An applicant must reapply for KHC benefits when eligibil-
ity for KHC benefits is terminated.
(f) A client who loses eligibility will not be reinstated until
all outstanding debts owed to the program by the client are paid or
arrangements acceptable to the program are made for payment.
(g) A client whose benefits are modified or suspended, or
whose eligibility is terminated, may appeal the program's decision
under 61.11 of this title (relating to Rights of Appeal).
(h) A provider's participation may be terminated or suspended
for any of the following reasons:
(1) loss of approval or exclusion from participation in the
Medicare program;
(2) exclusion from participation in the Medicaid program;
(3) providing false or misleading information regarding
any participation criteria;
(4) material breach of any contract or agreement with the
program;
(5) filing false or fraudulent information or claims for KHC
benefits;
(6) failure to submit a payable claim to the program during
a minimum period of 12 consecutive months; or
(7) failure to maintain the participation criteria contained
in 61.6(a) of this title.
(i) Providers may appeal a termination or suspension under
61.11 of this title.
61.11. Rights of Appeal.
(a) Administrative Review.
(1) When the program modifies, suspends, denies, or ter-
minates eligibility or benefits, the program shall give written notice of
and the reason for the action. Applicants, clients, and providers havethe right to request an administrative review of the action within 30
days of the notice date.
(2) If the program does not receive a written request for
administrative review within 30 days of the notice date, applicants,
clients, and providers waive the right to the administrative review
process.
(3) If a written request for administrative review is received
within 30 days of the notice date, the program conducts an administra-
tive review of the circumstances surrounding the action. The program
must give written notice of the decision including the supporting rea-
sons, within 30 days of receiving all information required to make a
determination regarding the request for an administrative review.
(4) The department establishes the KHC reimbursement
rates. Clients and providers may not request an administrative review
of reimbursement amounts for claims that are paid in accordance with
the reimbursement rates as described in 61.5 of this title (relating to
Benefits and Limitations).
(b) Fair Hearing.
(1) Applicants, clients, and providers who disagree with a
program administrative review decision may request a fair hearing in
writing addressed to Kidney Health Care, Purchased Health Services
Unit, MC 193 8, Department of State Health Services, P.O. Box 149347,
Austin, Texas 78714-9347, within 20 calendar days following the date
of receipt of the administrative review decision notice.
(2) If the fair hearing request is not received within 20 cal-
endar days following the date of the receipt of the administrative review
decision notice, the program will presume the fair hearing process has
been waived, and the program may take final action.
(3) A fair hearing shall be conducted in accordance with
1.51 - 1.55 of this title (relating to Fair Hearing Procedures).
(4) The program may not terminate KHC participation un-
til a final decision is rendered under the department's fair hearings
process.
(5) The program may withhold claims payment pending fi-
nal decision under the department's fair hearings process.
(6) The program must release any withheld payments
and reinstate participation if the final determination is in favor of the
provider.
(7) The program shall not enter into, extend, or renew an
agreement with a provider until a final decision is rendered under the
department's fair hearings process.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal author-
ity to adopt.
Filed with the Office of the Secretary of State on July 30, 2009.
TRD-200903221
Lisa Hernandez
General Counsel
Department of State Health Services
Earliest possible date of adoption: September 13, 2009
For further information, please call: (512) 458-7111 x6972
CHAPTER 229. FOOD AND DRUG34 TexReg 5476 August 14, 2009 Texas Register
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Texas. Secretary of State. Texas Register, Volume 34, Number 33, Pages 5445-5614, August 14, 2009, periodical, August 14, 2009; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth90865/m1/31/: accessed July 16, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.