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Revision 22-3; Effective Dec. 1, 2022
7410 Action Taken on the Hearing Decision
Revision 22-3; Effective Dec. 1, 2022
Program Support Unit (PSU) staff complete Form H4807, Action Taken on Hearing Decision, recording case actions taken. Managed care organizations (MCOs) can retrieve the information on the Texas Health and Human Services Commission (HHSC) State Benefits Portal.
7411 State Fair Hearing Reversal of Denial
Revision 22-3; Effective Dec. 1, 2022
If the State Fair Hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the managed care organization (MCO) appeal was pending, the MCO must authorize or provide the disputed services as expeditiously as the member’s health condition requires but no later than 72 hours from the date it receives notice reversing the determination. If the State Fair Hearing officer reverses a decision to deny authorization of services and the member received the disputed services while the appeal was pending, the MCO is responsible for the payment of services.
If the State Fair Hearing officer reverses an MCO's denial of a prior authorization for a durable medical equipment (DME) or DME service after the member has enrolled with a second MCO, the original MCO must pay for the DME service or equipment from the date it denied the authorization until the date the member enrolled with the second MCO. In the case of custom DME, the original MCO must pay for the custom DME if the denial is reversed.