4200, Appeal Procedures for Program Support Staff

Revision 14-1; Effective March 3, 2014

4210 PSU Specialist Procedures

Revision 19-3; Effective December 2, 2019

When a request for a fair hearing is received from an applicant or member, orally or in writing, Program Support Unit (PSU) staff must refer the request to the hearings officer within five calendar days from the date of the request. Upon receipt of the fair hearing request, the PSU specialist completes Form 4800-D, Fair Hearing Request Summary. The PSU specialist sends the form to the regional data entry representative (DER) and the supervisor within three calendar days of the request for a hearing. The three-day time frame allows the DER two days to enter the information into the Texas Integrated Eligibility Redesign System.

When PSU staff complete Form 4800-D, all questions in Section 3, Appellant Details Programs, must be answered. In Subsection D, Summary of Agency Action and Citation, staff must always answer “No” to the question, “Is there a good cause for non-timely?” as this question applies only to Texas Works programs.

PSU staff must indicate the Individual Service Plan (ISP) or Individual Plan of Care (IPC) begin and end dates, as applicable, in Section 3.D., Summary of Agency Action and Citation. The begin and end dates must also be mentioned during the fair hearing so the hearings officer is aware of when the ISP or IPC year ends when rendering a decision for STAR+PLUS Waiver.

The Form 4800-D format follows the data entry screens. See the Form 4800-D instructions for more specific directions for completion and transmittal.

4211 Designated DER Procedures

Revision 19-3; Effective December 2, 2019

Within two calendar days of receipt of Form 4800-D, Fair Hearing Request Summary, the data entry representative (DER) enters the information into the Fair Hearings and Appeals system in the Texas Integrated Eligibility Redesign System. When entry of all information is complete, the system assigns the appeal identification (ID) number. The DER notes the appeal ID number on the bottom of the form and in the designated space on the front of the form, and sends a copy back to the PSU specialist and his supervisor.

When an applicant or member requests a fair hearing, the burden of proof to uphold the PSU decision rests with the PSU. The hearings officer is a neutral party and is restricted by law from presenting the agency’s case. It is crucial that staff complete and organize all fair hearing packets in order to support the agency’s decision.

4212 Fair Hearings and Appeals Procedures

Revision 14-1; Effective March 3, 2014

The Texas Integrated Eligibility Redesign System generates a hearing packet, which includes:

The Program Support Unit (PSU) coordinator and his/her supervisor receive a copy of Form H4800 and Form H4803, identifying the fair hearings officer assigned to the appeal and the date, time and location of the hearing. PSU staff are not expected or required to attend fair hearings.

4213 Hearing Packet

Revision 21-2; Effective August 1, 2021

Use Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the fair hearings officer. Be sure documentation on the form clearly states this is a STAR+PLUS Program appeal. The appeal identification number assigned by the Texas Integrated Eligibility and Redesign System must be written on the top of Form H4800-A.

Use Form 4800-D, Fair Hearing Request Summary, to record the names, titles, addresses and telephone numbers of all persons, or their designees, who should attend the hearing. For appeal issues related to service delivery, enter the names of the designated managed care organization (MCO) staff and the designated backup. Program Support Unit (PSU) staff should contact the MCO if there is doubt as to who should be listed on Form 4800-D.

Depending on the issue being appealed, the following staff must attend:

  • MCO and Texas Medicaid & Healthcare Partnership (TMHP) (for medical necessity/level of care (MN/LOC) denials);
  • MCO (for denials of individual service plans (ISPs) over the cost ceiling); and
  • Medicaid for the Elderly and People with Disabilities (MEPD) (for financial denials).

All related documentation necessary to support the decision taken on an Home and Community-based (HCBS) STAR+PLUS Waiver (SPW) case must be sent to the fair hearings officer within 10 business days prior to the hearing. Each entity involved in the fair hearing is responsible for preparing its packet and forwarding it to both the hearings officer identified on Form H4803, Notice of Hearing, and the appellant. Be sure documentation on the form clearly states this is a STAR+PLUS Waiver Program appeal. All documentation must be neatly and logically organized, and all pages numbered.

Examples of additional information and who is responsible for submitting that information to the state fair hearings office include, but are not exclusively limited to:

  • MCO:
    • MCO policy handbook, STAR+PLUS Handbook and/or Uniform Managed Care Contract/Uniform Managed Care Manual;
    • summary of events;
    • other documentation supportive of the decision, such as documentation of telephone calls, visit summaries, etc.; and
    • copies of the signed Form H1700-1, Individual Service Plan, and Form H1700-3, Individual Service Plan – Signature Page, and all relevant attachments;
  • MEPD:
    • documentation supportive of the financial decision, including official documentation forms, telephone calls, etc.; and
    • a copy of the original signed denial form;
  • TMHP:
    • a copy of the MN/LOC; and
    • other documentation supporting the decision; and
  • PSU — a copy of the original signed Form H2065-D, Notification of Managed Care Program Services (if available, use the signed copy of the form returned by the applicant/member when the appeal was filed).

After the data entry representative (DER) has added information from Form 4800-D into the Texas Integrated Eligibility Redesign System (TIERS), PSU may learn of subsequent changes such as address changes, withdrawal forms or additional supporting documents needed for a fair hearing. When this occurs, PSU staff complete Form H4800-A with the updated information and submit it to the designated DER who will check TIERS to identify if a fair hearings officer has been assigned to the case. In the event the participant updates need to be communicated to the fair hearings officer, PSU staff complete and forward Form 4800-D to the DER.

If a fair hearings officer is not yet assigned, the DER must wait until one is assigned to send the additional information. When sending information, the DER completes the following activities according to the situation:

  • When PSU staff submit Form H4800-A or Form H4800-D to the DER, the DER sends the form(s) directly to the hearings officer’s email address with the appeal ID number in the subject line.
  • If the PSU staff submission to the DER includes additional supporting documentation for an appeal, the DER not only emails Form H4800 to the assigned hearings officer, but also uploads the supporting documentation directly into TIERS. The email sent by the DER must include the appeal ID number in the subject line, as referenced above, and inform the hearings officer that supporting documentation listed in Section 2 of Form H4800-A has been uploaded to TIERS.

PSU staff and the DER must follow current time frames and procedures to ensure supporting documentation is uploaded into TIERS no later than 10 calendar days prior to the fair hearing date.

4220 Special Procedures for Cases MEPD or TW Determined Financial Eligibility

Revision 14-1; Effective March 3, 2014

 

4221 Centralized Representation Unit

Revision 14-1; Effective March 3, 2014

The Health and Human Services Commission (HHSC) Office of Eligibility Services (OES) maintains a Centralized Representation Unit (CRU) to handle all hearings for Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works (TW) staff. CRU replaces the MEPD specialist in specific steps related to the denial of MEPD applications and ongoing cases. CRU:

  • represents HHSC OES in fair hearings, which includes both TW and MEPD;
  • completes and implements all TW/MEPD case actions based on fair hearing decisions; and
  • coordinates actions required with regional TW/MEPD staff and Program Support Unit (PSU) staff.

PSU staff must coordinate all appeals involving TW/MEPD-related eligibility with CRU. This includes HCBS STAR+PLUS Waiver (SPW) cases. The procedures in 4222, Centralized Representation Unit Procedures, must be used to coordinate appeal actions with CRU in cases for which MEPD staff determine financial eligibility.

Staff must remember CRU replaces the local TW/MEPD specialist in the following steps and that notices must not be sent to the local MEPD specialist, except as specified. All correspondence on appeals will go to the CRU supervisor and the CRU administrative assistant.

4222 Centralized Representation Unit Procedures

Revision 19-3; Effective December 2, 2019

Applicants/members may appeal a decision orally, in person or in writing. Program Support Unit (PSU) staff are responsible for completing Form 4800-D, Fair Hearing Request Summary, to file the appeal through the Texas Integrated Eligibility Redesign System (TIERS) when an applicant/member requests a fair hearing. The method in which the form is completed depends on the action being appealed. Staff must determine if the appealed action is:

  • a waiver/service denial (excludes denials based on Texas Works/Medicaid for the Elderly and People with Disabilities (TW/MEPD) denials); or
  • a TW/MEPD financial denial (denials based on a TW/MEPD denial action).

If the appealed action is related to a waiver/service denial, PSU staff complete Form 4800-D, entering the managed care organization contact as the Agency Representative. In the Other Participants field, PSU staff enter the Centralized Representation Unit (CRU) supervisor and CRU administrative assistant. The CRU supervisor and assistant names must be entered by using the Model Office Resources (MOR) Search function. This will assure that all the correct information is populated in the Texas Integrated Eligibility Redesign System (TIERS) and CRU staff will receive the notice of the appeal. Supplemental Security Income recipient appeals are not handled by CRU.

If the appealed action is a TW/MEPD financial denial, staff complete Form 4800-D and enter the name of the CRU supervisor as the agency representative. This information must be entered through the MOR Search function for CRU to receive the hearing information. List the PSU staff name and title in the Other Participants section. The name of the local TW/MEPD specialist is not entered by staff on Form 4800-D for TW/MEPD financial appeals. PSU staff must include staff title, such as PSU specialist or supervisor. Enter the staff email address and include the CRU administrative assistant in Other Participants. Her information must be entered through the MOR Search function.

If this is a TW/MEPD-related appeal, select "Yes" to the question in Section 6 which asks: "Are you an OES Texas Works or MEPD employee?" You are actually responding to this question on behalf of Kristi Rojas, so "Yes" is the correct response. On the Agency Representative page, select "Yes" in the drop-down menu. Failure to answer "Yes" to this item will result in CRU not being notified of the hearing. This paragraph only applies to TW/MEPD financial denials.

When Form 4800-D is sent to the designated data entry representative, PSU staff send an email notification regarding the request for an appeal to CRU. PSU staff will send the email to the HHSC Office of Eligibility Services (OES) Fair Hearings mailbox, which can be found in the Outlook Global Address List search box by typing HHSC OES Fair Hearings. In the subject line of the email, include the following: Request for Continued Benefits-MEPD Appeal ID-XXXXXXX. In an attachment to the email, staff must also include a copy of the notification form sent to the applicant or member.

The email must include:

  • applicant's/member's name;
  • Medicaid number (if available);
  • type of service (HCBS STAR+PLUS Waiver (SPW)); and
  • specific information requesting the TW/MEPD financial case remain active/open during the appeal, if the member appealed in a timely manner and requested continued benefits.

For example, the financial case may need to remain open pending an appeal decision regarding medical or functional eligibility. PSU staff must notify CRU to keep the TW/MEPD case open pending the fair hearing decision.

Upon receipt of notification of an appeal, CRU requests the TW/MEPD evidence packet from the local TW/MEPD specialist and completes any necessary actions required during the appeal process. The CRU supervisor assigns CRU staff to represent TW/MEPD at the hearing, if required, and takes steps to ensure the appropriate TW/MEPD financial case action is taken once a fair hearings officer's decision is rendered.

When a waiver/service denial hearing decision is rendered by the fair hearings officer, the PSU staff entered as "Agency Representative" is notified via email of the decision by the fair hearings officer. Based on the hearing decision, PSU staff determine the appropriate action for the waiver/services according to program-specific time frames. For more information, refer to 4500, Hearing Decision Actions.

PSU staff may need to coordinate effective dates of reinstatement with CRU and must email the CRU supervisor (with a copy to the CRU administrative assistant) for the coordination. PSU staff report the implementation of the hearing decision through TIERS on Form 4807-D, Action Taken on Hearing Decision, according to current procedures.

The local TW/MEPD specialist notifies PSU staff if an appeal is filed by TW/MEPD regarding a financial eligibility decision, and refers the TW/MEPD case to CRU to handle during the appeal process. Once the appeal decision regarding the MEPD financial case is rendered by the hearings officer, CRU must notify PSU staff via email of the hearing decision, including decisions that are sustained, reversed or withdrawn. Based on the hearing decision, staff determine the appropriate action for the waiver/service. The email sent by CRU includes:

  • applicant's/member's name;
  • Medicaid number;
  • a copy of the hearing decision; and
  • the effective or denial date of Medicaid eligibility.

Staff must not put an applicant/member back on waiver/service-specific interest lists while a TW/MEPD denial is in the appeal process. PSU staff must take appropriate action to certify or deny the case, or resume services once the TW/MEPD hearing decision is rendered. The individual may choose to be added back to the waiver/service-specific interest list once staff deny the waiver/service. 

4230 Regional Responsibilities

Revision 14-1; Effective March 3, 2014

 

4231 Uploading the Appeals Evidence Packet into the TIERS Application

Revision 14-1; Effective March 3, 2014

All evidence packets must be scanned into the Texas Integrated Eligibility Redesign System (TIERS) Appeals application using the process described below. The regional data entry representative (DER) uses Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation (also referred to as the appeals packet) to the fair hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A.

At least 12 business days prior to the fair hearing date, the case manager or Program Support Unit (PSU) specialist must:

  • go to the multi-function office Workcenter and scan in the documentation;
  • save the document by either allowing the default document name or entering a name of the user's choosing;
  • retrieve the scanned document and attach it to an email; and
  • send the document to the regional DER.

Within two business days after receipt, the DER must:

  • save the attachment to the appropriate network drive, as assigned by regional management;
  • go into the TIERS portal and select the Appeals tab, without launching TIERS;
  • ensure the appeal has been entered in TIERS (this requirement must be met before the next step can be completed);
  • select Hearing Evidence Packets Upload and enter the Appeal ID;
  • select Document Type: Agency Evidence Packet (items entered in any other selection will not be included in the evidence packet);
  • select Validate;
  • check the details to ensure the right person has been selected;
  • browse for the document; and
  • select Upload.

Users who make mistakes they are unable to reverse may contact the state office Document Maintenance manager to assist in correcting the error and uploading the appropriate information.

4232 Presentation of the Hearing Packet

Revision 14-1; Effective March 3, 2014

The Texas Integrated Eligibility Redesign System generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The Program Support Unit (PSU) specialist and his/her supervisor receive a copy of Form H4800 and Form H4803, identifying the hearings officer assigned and the date, time and location of the hearing. PSU staff are not expected or required to attend fair hearings.

4233 Presentation of the Evidence

Revision 14-1; Effective March 3, 2014

Documentation contained in the fair hearing packet is not considered in the case decision unless the packet is offered into evidence. To accomplish this requirement, the agency representative must present the packet, ask that it be submitted as evidence and summarize what the packet contains.

Example: "I want to offer the following packet as evidence in the appeal filed on the behalf of Ned Flanders. Pages 1-10 contain information relating to the completion of Form H2060, Needs Assessment Questionnaire and Task/Hour Guide. Pages 11-15 contain policy from the STAR+PLUS Handbook that relates directly to the issue in question. Pages 16-20 contain documents signed by the applicant related to individual rights. Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant on March 2, 2011."

The fair hearings officer then asks for objections and admits the documents into evidence. If any documents are not admitted, the fair hearings officer explains the reasons for excluding the material. Any documents admitted by the fair hearings officer are considered when a decision is rendered.

4234 Hearing Decision

Revision 14-1; Effective March 3, 2014

After the hearing is held, the fair hearings officer sends a decision letter to the appellant and copies to the Program Support Unit (PSU) specialist and his/her supervisor. If the decision is sustained, the PSU specialist takes the appropriate action. If the member requested continued services during the appeal period, follow procedures as described in 4500, Hearing Decision Actions.

If the action is reversed, the fair hearings officer also sends Form H4807, Action Taken on Hearing Decision. The fair hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. The PSU specialist actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System within the 10-day time frame designated by the hearings officer.