Form 2128, 120 Day Notice

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Documents

Effective Date: 8/2023

Instructions

Updated: 8/2023

Purpose

Form 2128 and Form 2128-S, 120 Day Notice, notifies a member who requested first position, to move up on another 1915(c) waiver interest list, or both, that Program Support Unit (PSU) staff cannot process the member’s request. This is because the member did not provide their request within 120 days from the date PSU staff generated and mailed:

  • Form H2065-D, Notification of Managed Care Program Services, and Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denial - Members, for members denied medical necessity (MN); or
  • Form H2065-D and Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP, for members transitioning from MDCP to an adult program.

Procedure

When to Prepare

PSU staff prepare Form 2128 and Form 2128-S when a member requests first position, to move up on another 1915(c) waiver interest list, or both after 120 days from the date PSU staff generated and mailed:

  • Form H2065-D and Appendix XXIV for members denied MN; or
  • Form H2065-D and Appendix XXIX for members transitioning from MDCP to an adult program.

Copies and Transmittal

PSU staff mail the original Form 2128 and 2128-S to the member or the member’s medical consenter or legally authorized representative (LAR) as applicable.

Form Retention

Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) is the electronic case record for MDCP. PSU staff will not retain paper copies of Form 2128 and Form 2128-S. PSU staff disposes of paper copies of Form 2128 and Form 2128-S by following established procedures for destroying confidential data, as described in the HHS Computer Usage and Information Security Training. PSU staff uploads a copy of Form 2128 and Form 2128-S to the HEART case record.

Supply Source

Form 2128 and Form 2128-S are located in the STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH).

Detailed Instructions

Upper right section:

Date of notice — Enter the date PSU staff complete and mail the form to the member or the member’s medical consenter or LAR.

Office area code and phone no. — Enter the office area code and phone number.

Office street and P.O. Box address — Enter the office street address or post office box.

Office mail code, city, state and ZIP code — Enter the office mail code, city, state and ZIP code.

Upper left section:

Member’s full name – Enter the member’s full name.

Street or P.O. Box address — Enter the member or the member’s medical consenter or LAR’s mailing address. Include the post office box, mail code, city, state and ZIP code. For STAR Health, this will be the address of the medical consenter provided by the STAR Health managed care organization (MCO).

City, state and ZIP code — Enter the member or the member’s medical consenter or the LAR’s city, state and zip code.

Select an Option —

  • for first position;
  • to move up on another 1915(c) waiver program interest list; or
  • for first position and to move up on another 1915(c) waiver program interest list.

Lower left section:

Signature of PSU — Enter the signature of the PSU staff.

PSU Staff’s Printed Name — Enter the printed name of the PSU staff.