1. (a) An applicant for oral health treatment services must be referred to the program by a third-party nominator who knows the individual's economic condition.

2. (b) Each applicant for oral health treatment services must complete or cause to be completed an application form, which shall include the following information for the individual needing services:

   1. (1) personal information, including name, address, birthdate, gender and ethnicity;
   2. (2) a statement from the referring third-party nominator that the oral health treatment services are necessary to prevent or reduce the probability of pain, infection, or disease; and

   3. (3) a statement by the applicant or the person responsible for the applicant's support that:

      1. (A) services are requested;
      2. (B) the applicant is a bona fide resident of Texas and the family income does not exceed the financial guidelines as required in §49.6 of this title (relating to Eligibility Requirements for Referral);
      3. (C) the applicant is not eligible for another program or other benefit providing dental care; and
      4. (D) the applicant or the person responsible for the applicant's support is financially unable to pay for all or part of the cost of the necessary oral health treatment services.
3. (c) Each applicant who will be referred for oral health treatment services, as described in §49.7 of this title (relating to Eligibility Requirements to Receive Oral Health Treatment Services), must have his/her application prior authorized in accordance with program policies and procedures, as defined in the Manual and any updates, changes, and amendments.
4. (d) The denial of any application must be in writing and must include the reason(s) for such denial. Unless the application is denied because program funds are reduced, curtailed, or unavailable, the individual applying for oral health treatment services has the right to an administrative review and a due process hearing in accordance with Subchapter D of this chapter (relating to Appeals Process).
5. (e) An individual has the right to reapply for program coverage at any time when there is a change of situation or condition.

Source Note:The provisions of this §49.5 adopted to be effective October 16, 2008, 33 TexReg 8522.