1. (a) General provisions.

   1. (1) Definitions. The following words or terms, when used in this section, shall have the following meaning, unless the context clearly indicates otherwise.

      1. (A) Formal appeal--An administrative hearing requested by an interested party under subsection (d) of this section and conducted in accordance with procedures described at 40 TAC §§79.1601-79.1614 (Formal Appeals);
      2. (B) Informal review--The informal reexamination of an action or determination by the Texas Department of Human Services (DHS) under this chapter requested by an interested party and conducted in accordance with subsection (c) of this section.
      3. (C) Interested party--A DHS-contracted provider.
   2. (2) Standing to file informal reviews or formal appeals. Only an interested party has standing to file for an informal review or formal appeal under this section.
   3. (3) Subject matter of informal reviews and formal appeals. An interested party may request an informal review or formal appeal regarding a DHS action or determination under §355.102 of this title (relating to General Principles of Allowable and Unallowable Costs), §355.103 of this title (relating to Specifications for Allowable and Unallowable Costs), §355.104 of this title (relating to Revenues), and §355.105 (relating to General Reporting and Documentation Requirements, Methods and Procedures), or program-specific allowable or unallowable costs, taken specifically in regard to the interested party.

2. (b) Separation of informal reviews and formal appeals from the reimbursement determination process.

   1. (1) The filing of a request for an informal review or formal appeal under this section does not stay or delay implementation of reimbursement adopted by DHS in accordance with the requirements of this chapter.

   2. (2) Closure of cost report databases used in the reimbursement determination process and application of results of pending review or appeal. To facilitate the timely and efficient calculation of reimbursement amounts, DHS closes cost report databases used in the reimbursement determination process prior to the proposal of reimbursement amounts.

      1. (A) Impact on database of pending informal review or formal appeal. If an informal review is pending at the time the database is closed, the database shall include the interested party's cost report data including any adjustments made either in the desk review or field audit. If a formal appeal is pending at the time the database is closed, the database shall include the interested party's cost report data including any adjustments required as a result of the informal review.

      2. (B) Uniform reimbursement.

         1. (i) For programs where reimbursement is uniform by class of service and/or provider type, the cost report database used in reimbursement determination is closed six weeks prior to the public hearing on the proposed reimbursement that is based on the cost report database.
         2. (ii) If an informal review or formal appeal is pending at the time the cost report database is closed, the results of the informal review or formal appeal shall be applied during the next reimbursement determination cycle, if applicable.

      3. (C) Contractor-specific reimbursement.

         1. (i) For programs where reimbursement is contractor-specific the cost report database is closed ten weeks prior to the end of the reimbursement determination cycle.
         2. (ii) If an informal review or formal appeal is pending at the time the cost report database is closed, the results of the informal review or formal appeal shall be applied to the interested party's payment retroactively to the beginning of the current reimbursement determination cycle. The results of the informal review or formal appeal shall not be applied to the cost report database as a whole or to any other reimbursement amounts influenced by the cost report database as a whole until the next reimbursement determination cycle, if applicable.

3. (c) Informal review.

   1. (1) An interested party who disputes a DHS action or determination under this chapter may request an informal review under this section. The purpose of an informal review is to provide for the informal and efficient resolution of the matters in dispute. An informal review is not a formal administrative hearing, but is a prerequisite to obtaining a formal administrative hearing and is conducted according to the following procedures:

      1. (A) The interested party must contact the Rate Analysis Department in writing by U.S. mail or special mail delivery within 20 calendar days of the date on DHS's written notification of the exclusions or adjustments to request an informal review.
      2. (B) An interested party must, with its request for an informal review, submit a concise statement of the specific actions or determinations it disputes, its recommended resolution, and any supporting documentation the interested party deems relevant to the dispute. It is the responsibility of the interested party to render all pertinent information at the time of its request for an informal review.

   2. (2) On receipt of a request for informal review, the commissioner or his designee assigns the review to appropriate DHS staff.

      1. (A) The lead staff member coordinates a review by appropriate DHS staff of the information submitted by the interested party. Staff may request additional information from the interested party, which must be received in writing by the lead staff member within 14 calendar days of the request for additional information. Information received after 14 days may not be used in the panel's written decision unless the interested party receives approval of the lead DHS staff member to submit the information after 14 days.
      2. (B) Within 30 days of the date the request for informal review is received by DHS or the date additional requested information is received by DHS, the lead staff member must send the interested party its written decision by certified mail, return receipt requested.
4. (d) Administrative hearings. An interested party who disagrees with the results of an informal review conducted under subsection (c) of this section may file a formal appeal of the review. The interested party must file a written request for a formal appeal with the Hearings Department, Texas Department of Human Services, Mail Code W-613, P.O. Box 149030, Austin, Texas 78714-9030, within 15 calendar days after receiving the DHS review panel's written decision as specified in subsection (c) of this section. The formal appeal is limited to the issues that were considered in the informal review process. The information from the interested party is limited to the pertinent information considered in the informal review process. DHS conducts formal appeals in accordance with the provisions of 40 TAC §§79.1601-79.1614 (Formal Appeals). If there is a conflict between the applicable section of 40 TAC Chapter 79 (Legal Services) and the provisions of this chapter, the provisions of this chapter prevail.

Source Note:The provisions of this §355.110 adopted to be effective September 1, 1996, 21 TexReg 7866; duplicated effective September 1, 1997, as published in the Texas Register October 17, 1997, 22 TexReg 10311; amended to be effective June 26, 2000, 25 TexReg 6089.