An official State of Texas website.
Revision 25-1; Effective March 3, 2025
When managed care organization (MCO) staff enter fair hearing requests in the Texas Integrated Eligibility Redesign System (TIERS), as outlined in the policy below, use the following entries per the Community First Choice (CFC) medical necessity level of care (MN/LOC) denial being appealed:
- For MN/LOC State Fair Hearing fair hearing requests:
- Program: Community Care
- Type of Assistance (TOA): Community First Choice
- Issue Code: 57 - Medical Necessity
- For intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) LOC or institutions for mental diseases LOC fair hearing requests:
- Program: Community Care
- TOA: Community First Choice
- Issue Code: 99 - Other - Only use this code in rare instances when there is not a more appropriate code.
STAR Kids Screening and Assessment Instrument (SK-SAI) Denials for Initial or Reassessment Eligibility
As part of the CFC eligibility determination process, the MCO is responsible for completing the SK-SAI assessment to determine MN/LOC. The MCO then submits the SK-SAI assessment to the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for approval of the MN/LOC determination. Based on the automatic TMHP Medicaid Management Information System (MMIS) decision, the following occurs:
- If the TMHP MMIS automatically approves MN or if HHSC Office of Medical Director (OMD) Waiver Eligibility staff approves MN on the initial or reassessment SK SAI:
- the TMHP MMIS notifies the MCO that the member meets MN criteria; and
- the MCO authorizes CFC services.
- If the HHSC OMD Waiver Eligibility physician denies MN on an initial or reassessment SK-SAI, TMHP notifies the MCO that the member does not meet MN. The MCO must follow appeal procedures outlined in the Uniform Managed Care Manual (UMCM) and take the following action based on the member's situation:
- For MN denials when the member is not requesting or receiving Medically Dependent Children Program (MDCP) program services, the MCO sends the member a denial notice with fair hearing rights. The MCO must include the required elements in the notice. This information is incorporated in requirements outlined in the UMCM.
- If the member requests a fair hearing, the MCO must enter the fair hearing in the TIERS and attend the fair hearing.
- HHSC OMD Waiver Eligibility staff is also required to attend the fair hearing because HHSC is the entity making the LOC decision.
For MN denials when the member is requesting or receiving CFC services and MDCP program services, the MCO must post Form H2067-MC, Managed Care Programs Communication (PDF), to MCOHub in two business days of receiving the notice from the TMHP MMIS and when the assessment is in MN denied status. This is to notify the Program Support Unit (PSU) of the denial and that the member requested or is receiving both MDCP and CFC services. PSU sends the member a denial notice Form H2065-D, Notification of Managed Care Program Services (PDF) for MDCP with fair hearing rights. The notice instructs the member to contact PSU staff to request a state fair hearing. If a member makes this request, PSU:
- enters the fair hearing in TIERS within five days; and
- identifies T HHSC OMD Waiver Eligibility as the agency representative.
The MCO also attends the fair hearing as the agency witness. The local intellectual and developmental disability authority or local mental health authority may also be required to attend as an agency representative for state fair hearings. If the member requests a timely fair hearing at reassessment and requests continued benefits, the MCO continues services pending the outcome of the fair hearing.