Appendix I, Fair Hearing Case Record Filing Guide

Revision 14-1; March 31, 2014

Always file the most current material on top of the appropriate section.

Left Side of FolderRight Side of Folder

Topmost item(s) are:

  • Fair hearing tracking sheet or Form H4809, Update After Fair Hearing Data Entry Form

Topmost item(s) are:

  • Decision cover letter
  • Fair hearing decision

Use tabs to separate the remaining items:

Correspondence (most recent on top)Administrative Review (for use as needed)

Examples include, but are not limited to:

  • Emails regarding the fair hearing
  • Form H4800, Fair Hearing Request Summary; Form H4803, Notice of Hearing; Form H4804, Request and Authorization for Fair Hearing Record to Remain Open; Form H4806, Request for Another Appointment - Request to Withdraw; and Form H4807, Action Taken on Hearing Decision
  • Appellant's statement of representation
  • Appellant's postponement request

Note: If any of these documents become exhibits, label and file under Exhibits Admitted instead.

Examples include, but are not limited to:

  • Appellant's administrative review request and any accompanying documents
  • Hearings administrator email
  • Email with name of attorney assigned to review
  • Emails relating to decision and/or review
  • Recording of hearing (tape or CD)

Reopen: (for use as needed)

  • Appellant’s request to reopen appeal and any accompanying documents
Exhibits Not Admitted: (for use as needed)Exhibits Admitted:
  • Items determined irrelevant or otherwise inadmissible by the hearings officer
  • Items provided to the hearings officer, but not offered by participants
  • Duplicates of exhibits admitted
  • File exhibits in ascending numeric order

Appendix II, Area Boxes and Email Addresses

Revision 23-1; Effective July 31, 2023

A general email is assigned to each of the five areas under the Fair Hearings section.

AreaEmail Address
1appealsinfoarea1@hhsc.state.tx.us
3appealsinfoarea2@hhsc.state.tx.us
3FFH_appealsinfo3@hhsc.state.tx.us
4appealsevidence@hhsc.state.tx.us
5appealsinfoarea5@hhsc.state.tx.us
All RegionsOCC_Appeals_FairandFraudHearings@hhsc.state.tx.us

Appendix III, Distribution Schedule

Revision 10-1; January 15, 2010

Appeals Received via TIERS

Agency Rep4803
Batch
4803
Alert/TLM
Decision AlertDismiss Decision EmailedWithdraw
Decision Emailed
Sustain
Decision Emailed
Reversed Decision Emailed
OES   
DADS  
HMOs   
TMHP   
OIG   
DSHS/ PCS   
DSHS/ MH   
Other Participant  

Notes:

  1. Effective Dec. 21, 2009, 4803s to agency reps will not be batched if an alert is generated.
  2. If the 4803 is generated in batch or an alert is generated, it is not necessary to e-mail an appointment notice.
  3. Effective June 1, 2009, send TMHP sustain and reverse decisions to the CARD e-mail address at: card@tmhp.com.
  4. Send OES sustained and reversed decisions to the OES Fair Hearing e-mail address at: oesfairhearing@hhsc.state.tx.us.

Appendix IV, Partial Settlement Agreement, Exhibit B

Revision 10-4; July 16, 2010

Partial Settlement Agreement, Exhibit B

Appendix V, Health Plan Management

Revision 11-4; June 1, 2011

Health Plan Management

Appendix VI, Decision Types

Revision 23-1; Effective July 31, 2023

The hearings officer issues a decision for every appeal requested. There are several types of fair hearing decisions:

Decision TypeDefinition
Dismissed – AbandonmentThis decision type should be used when the appellant disconnects from the hearing and does not call back in.
Dismissed - Failure to AppearThis decision type should be used when the appellant or appellant’s authorized representative fails to appear for a scheduled hearing or pre-hearing conference.
Dismissed – Generic

This decision type should be used when:    

  • the appeal was added in error;
  • a decision was already issued; or
  • in CHIP denials.
Dismissed – 90-Day No Jurisdiction (Untimely Request)

This decision type should be used when: 

  • Non-managed care cases: appellant takes more than 90 days (without good cause) from the date of the action on appeal or the effective date, whichever is longer, to request a fair hearing. 
  • Managed care cases: appellant takes more than 120 days (without good cause) from the date the internal appeal was completed or exhausted to request a fair hearing.
Dismissed – Want of JurisdictionThis decision should be used when the Fair Hearings department does not have jurisdiction and the appeal is not in the 90-Day No Jurisdiction category (untimely request over 90 days for non-managed or 120 days for managed care).
Reversed – Benefits DueThis decision type should be used when the hearings officer determines the agency’s action was not appropriate according to policy and law, and the agency is ordered to approve or issue benefits or services.
Reversed – Information NeededThis decision type should be used when the hearings officer determines the agency’s action was not appropriate according to policy and law, but it is not clear whether benefits are due.
Reversed – No Benefits DueThis decision type should be used when the hearings officer determines the agency’s action was not appropriate according to policy and law but did not result in a loss of benefits or services.
SustainedThis decision type should be used when the hearings officer determines the agency’s action was appropriate according to policy and law.
Sustained with InstructionsThis decision type should be used when the hearings officer determines the agency’s action was appropriate according to policy and law at the time of the initial determination; however, new information obtained during the hearing requires additional action by the agency.
Withdrawn – Favorable ActionThis decision type should be used when the appellant or appellant’s representative withdraws the appeal after the agency corrects or overturns its original decision in the appellant’s favor.
Withdrawn – SustainedThis decision type should be used when the appellant or appellant’s representative withdraws the appeal, and the agency’s action was correct, or the hearings officer is unable to determine whether the agency’s action was correct.

Appendix VII, Administrative Disqualification Hearing (ADH) Case Record Filing Guide

Revision 14-1; March 31, 2014

Always file the most current material on top of the appropriate section.

Left Side of FolderRight Side of Folder

Topmost item(s) are:

  • ADH tracking sheet
  • MAPPER entry screen printout
  • AVAYA printout

 

Topmost item(s) are:

  • Decision cover letter
  • Form H4857, Notice of Decision, Administrative Disqualification Hearing
  • ADH decision

Use tabs to separate the remaining items:

Correspondence: (most recent on top)Administrative Review: (for use as needed)

Examples include, but are not limited to:

  • Email requesting the ADH
  • ADH case summary
  • Form H4851-C, Notice of Administrative Disqualification Hearing
  • Form H4856, Request for Another Appointment for Administrative Disqualification Hearing
  • USPS certified mail receipt
  • USPS domestic return receipt
  • Respondent’s statement of representation

Note: If any of these documents become exhibits, label and file under Exhibits Admitted instead.

  • Respondent’s administrative review request and any accompanying documents

Reopen: (for use as needed)

  • Respondent’s reopen request and any accompanying documents
Exhibits Not Admitted:Exhibits Admitted:
  • Items determined irrelevant or otherwise inadmissible by the hearings officer
  • Items provided to the hearings officer, but not offered by participants
  • Duplicates of exhibits already admitted
  • File exhibits in ascending order.
  • When items are offered independently, label them as the next logical exhibit number or letter. Example: Exhibits A through E are offered. Then an Office of Inspector General (OIG) representative offers five additional pages which are not included in A through E and are not labeled. These pages should be numbered one to five and labeled as exhibit F.

Appendix VIII, Counties Serviced by Region

Revision 15-2; November 20, 2015

RegionCounties Serviced
Region 1: High PlainsArmstrong, Bailey, Briscoe, Carson, Castro, Childress, Cochran, Collingsworth, Crosby, Dallam, Deaf Smith, Dickens, Donley, Floyd, Garza, Gray, Hale, Hall, Hansford, Hartley, Hemphill, Hockley, Hutchinson, King, Lamb, Lipscomb, Lubbock, Lynn, Moore, Motley, Ochiltree, Oldham, Parmer, Potter, Randall, Roberts, Sherman, Swisher, Terry, Wheeler, Yoakum
Region 2: Northwest TexasArcher, Baylor, Brown, Callahan, Clay, Coleman, Comanche, Cottle, Eastland, Fisher, Foard, Hardeman, Haskell, Jack, Jones, Kent, Knox, Mitchell, Montague, Nolan, Runnels, Scurry, Shackelford, Stonewall, Stephens, Taylor, Throckmorton, Wichita, Wilbarger, Young
Region 3: MetroplexCollin, Cooke, Dallas, Denton, Ellis, Erath, Fannin, Grayson, Hood, Hunt, Johnson, Kaufman, Navarro, Palo Pinto, Parker, Rockwall, Somervell, Tarrant, Wise
Region 4: Upper East TexasAnderson, Bowie, Camp, Cass, Cherokee, Delta, Franklin, Gregg, Harrison, Henderson, Hopkins, Lamar, Marion, Morris, Panola, Rains, Red River, Rusk, Smith, Titus, Upshur, Van Zandt, Wood
Region 5: Southeast TexasAngelina, Hardin, Houston, Jasper, Jefferson, Nacogdoches, Newton, Orange, Polk, Sabine, San Augustine, San Jacinto, Shelby, Trinity, Tyler
Region 6: Gulf CoastAustin, Brazoria, Chambers, Colorado, Fort Bend, Galveston, Harris, Liberty, Matagorda, Montgomery, Walker, Waller, Wharton
Region 7: Central TexasBastrop, Bell, Blanco, Bosque, Brazos, Burleson, Burnet, Caldwell, Coryell, Falls, Fayette, Freestone, Grimes, Hamilton, Hays, Hill, Lampasas, Lee, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills, Robertson, San Saba, Travis, Washington, Williamson
Region 8: Upper South TexasAtascosa, Bandera, Bexar, Calhoun, Comal, DeWitt, Dimmit, Edwards, Frio, Gillespie, Goliad, Gonzales, Guadalupe, Jackson, Karnes, Kendall, Kerr, Kinney, La Salle, Lavaca, Maverick, Medina, Real, Uvalde, Val Verde, Victoria, Wilson, Zavala
Region 9: West TexasAndrews, Borden, Coke, Concho, Crane, Crockett, Dawson, Ector, Gaines, Glasscock, Howard, Irion, Kimble, Loving, Martin, Mason, McCulloch, Menard, Midland, Pecos, Reagan, Reeves, Schleicher, Sterling, Sutton, Terrell, Tom Green, Upton, Ward, Winkler
Region 10: Upper Rio GrandeBrewster, Culberson, El Paso, Hudspeth, Jeff Davis, Presidio
Region 11: Lower South TexasAransas, Bee, Brooks, Cameron, Duval, Hidalgo, Jim Hogg, Jim Wells, Kenedy, Kleberg, Live Oak, McMullen, Nueces, Refugio, San Patricio, Starr, Webb, Willacy, Zapata