The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise:

1. (1) Action--

   1. (A) Termination, suspension, or reduction of Medicaid eligibility or covered services by an operating agency or its designee, including:

      1. (i) the denial of Medicaid eligibility;
      2. (ii) the denial of program eligibility;
      3. (iii) the denial of a prior authorization request for covered services; and
      4. (iv) the failure of an operating agency or its designee to act within a reasonable amount of time on an individual's request for Medicaid covered services or for an eligibility determination.
   2. (B) A decision made by an operating agency or its designee concerning disenrollment from an MCO.
   3. (C) An adverse determination made by an operating agency or its designee with regard to the preadmission screening and annual resident review.

   4. (D) When an MCO:

      1. (i) denies or limits authorization of a requested service, including the type or level of service;
      2. (ii) reduces, suspends, or terminates a previously authorized service;
      3. (iii) denies, in whole or part, payment for services for dates of service on or after August 13, 2003;
      4. (iv) fails to provide services in a timely manner;
      5. (v) fails to act within the timeframes for resolution of an MCO appeal required by contract under 42 CFR §438.408(b); or
      6. (vi) denies a request from an individual, who is a resident of a rural area with only one MCO, to exercise his or her right, under 42 CFR §438.52(b)(2)(ii), to obtain services outside the network.
   5. (E) A determination by a skilled nursing facility or nursing facility to transfer or discharge a resident.
   6. (F) "Action" does not include expiration of a time-limited service.
2. (2) Adverse determination--Determination that the individual does not require the level of services provided by a nursing facility or that the individual does or does not require specialized services.
3. (3) Appeal--a request for review of an action, usually taken by an MCO.
4. (4) Date of action--The intended date on which a termination, suspension, reduction, transfer, or discharge becomes effective. It also means the date of the determination made by an operating agency with regard to the preadmission screening and resident review.
5. (5) Day--Calendar day, unless otherwise specified.
6. (6) Designee--A contractor of an operating agency authorized to take an action or adverse determination as defined in paragraphs (1) and (2) of this section on behalf of the operating agency.

7. (7) Fair Hearing--

   1. (A) Expedited Fair Hearing--A fair hearing conducted by an operating agency and held within 3 business days after the receipt of the case file from the MCO for an individual who has exhausted the MCO's expedited appeal process.
   2. (B) Standard Fair Hearing--A fair hearing conducted by an operating agency and held in accordance with this chapter in which a decision is made within 90 days after the receipt of a request.
8. (8) Grievance--an expression of dissatisfaction about any matter other than an "action". A grievance is not subject to the state fair hearing process.

9. (9) MCO Appeals--

   1. (A) Expedited MCO appeal--An appeal conducted by an MCO and held within 3 business days after receipt of a request because the individual's health condition meets the criteria for an expedited MCO appeal, determined in accordance with §357.1(b)(2) of this title (relating to Purpose and Scope)
   2. (B) Standard MCO appeal--An appeal conducted by an MCO and held within 30 days after receipt of the request.
10. (10) MCO--Medicaid managed care organization. An entity that has a current Texas Department of Insurance certificate of authority to operate as an HMO under Chapter 843 of the Texas Insurance Code or as an approved nonprofit health corporation under Chapter 844 of the Texas Insurance Code.
11. (11) Medicaid eligibility--The eligibility of an individual to receive services under the Texas Medicaid program.
12. (12) Operating agency--A state agency operating part of the Title XIX (Medicaid) program under the Social Security Act and includes the Department of Health, the Department of Human Services, the Rehabilitation Commission, and the Department of Mental Health and Mental Retardation , and the Health and Human Services Commission .
13. (13) Prior authorization request--a request for services that are reimbursable only when authorization or approval is obtained before services are rendered. Prior authorized services may be limited in duration, scope, and amount. Services provided beyond those authorized are not reimbursable. If a prior authorization is limited in duration, scope, or amount, a separate request and approval must be obtained for each prior authorized service.
14. (14) Program eligibility--The eligibility of an individual to receive services within a particular Medicaid program.

Source Note:The provisions of this §357.3 adopted to be effective March 31, 1999, 24 TexReg 2293; amended to be effective November 16, 2003, 28 TexReg 9806.