Appendices
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 Folder | Right Side of Folder |
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Topmost item(s) are:
| Topmost item(s) are:
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Use tabs to separate the remaining items:
Correspondence (most recent on top) | Administrative Review (for use as needed) |
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Examples include, but are not limited to:
Note: If any of these documents become exhibits, label and file under Exhibits Admitted instead. | Examples include, but are not limited to:
Reopen: (for use as needed)
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Exhibits Not Admitted: (for use as needed) | Exhibits Admitted: |
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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.
Appendix III, Distribution Schedule
Revision 10-1; January 15, 2010
Appeals Received via TIERS
Agency Rep | 4803 Batch | 4803 Alert/TLM | Decision Alert | Dismiss Decision Emailed | Withdraw Decision Emailed | Sustain Decision Emailed | Reversed Decision Emailed |
---|---|---|---|---|---|---|---|
OES | ● | ● | ● | ● | |||
DADS | ● | ● | ● | ● | ● | ||
HMOs | ● | ● | ● | ● | |||
TMHP | ● | ● | ● | ● | |||
OIG | ● | ● | ● | ● | |||
DSHS/ PCS | ● | ● | ● | ● | |||
DSHS/ MH | ● | ● | ● | ● | |||
Other Participant | ● | ● | ● | ● | ● |
Notes:
- Effective Dec. 21, 2009, 4803s to agency reps will not be batched if an alert is generated.
- If the 4803 is generated in batch or an alert is generated, it is not necessary to e-mail an appointment notice.
- Effective June 1, 2009, send TMHP sustain and reverse decisions to the CARD e-mail address at: card@tmhp.com.
- 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
Appendix V, Health Plan Management
Revision 11-4; June 1, 2011
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 Type | Definition |
---|---|
Dismissed – Abandonment | This decision type should be used when the appellant disconnects from the hearing and does not call back in. |
Dismissed - Failure to Appear | This 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:
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Dismissed – 90-Day No Jurisdiction (Untimely Request) | This decision type should be used when:
|
Dismissed – Want of Jurisdiction | This 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 Due | This 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 Needed | This 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 Due | This 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. |
Sustained | This decision type should be used when the hearings officer determines the agency’s action was appropriate according to policy and law. |
Sustained with Instructions | This 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 Action | This 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 – Sustained | This 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 Folder | Right Side of Folder |
---|---|
Topmost item(s) are:
| Topmost item(s) are:
|
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:
Note: If any of these documents become exhibits, label and file under Exhibits Admitted instead. |
Reopen: (for use as needed)
|
Exhibits Not Admitted: | Exhibits Admitted: |
---|---|
|
|
Appendix VIII, Counties Serviced by Region
Revision 15-2; November 20, 2015
Region | Counties Serviced |
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Region 1: High Plains | Armstrong, 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 Texas | Archer, 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: Metroplex | Collin, Cooke, Dallas, Denton, Ellis, Erath, Fannin, Grayson, Hood, Hunt, Johnson, Kaufman, Navarro, Palo Pinto, Parker, Rockwall, Somervell, Tarrant, Wise |
Region 4: Upper East Texas | Anderson, 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 Texas | Angelina, Hardin, Houston, Jasper, Jefferson, Nacogdoches, Newton, Orange, Polk, Sabine, San Augustine, San Jacinto, Shelby, Trinity, Tyler |
Region 6: Gulf Coast | Austin, Brazoria, Chambers, Colorado, Fort Bend, Galveston, Harris, Liberty, Matagorda, Montgomery, Walker, Waller, Wharton |
Region 7: Central Texas | Bastrop, 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 Texas | Atascosa, 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 Texas | Andrews, 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 Grande | Brewster, Culberson, El Paso, Hudspeth, Jeff Davis, Presidio |
Region 11: Lower South Texas | Aransas, Bee, Brooks, Cameron, Duval, Hidalgo, Jim Hogg, Jim Wells, Kenedy, Kleberg, Live Oak, McMullen, Nueces, Refugio, San Patricio, Starr, Webb, Willacy, Zapata |