Section 261.263 - Informal Review and Administrative Hearing(a) Informal review. (1) A program provider that disputes the report of findings described in § 261.262(d) of this chapter (relating to Trust Fund Monitoring and Audits) may request an informal review. The purpose of an informal review is to provide for the informal and efficient resolution of the matters in dispute. An informal review is conducted according to the following procedures: (A) DADS must receive a written request for an informal review by United States (U.S.) mail, hand delivery, special mail delivery, or fax no later than 15 days after the date on the written notification of the report of findings described in § 261.262(d) of this chapter. (i) If the 15th day is a Saturday, Sunday, national holiday, or state holiday, then the first working day after the 15th day is the final day the written request is accepted.(ii) A request for an informal review that is not received by the stated deadline is not accepted.(B) A program provider must submit a written request for an informal review: (i) by U.S. mail to DADS Trust Fund Monitoring Unit, Attn: Manager, P.O. Box 149030, Mail Code W-340, Austin, Texas 78714-9030;(ii) hand delivery or special mail delivery to 701 West 51st Street, Austin, Texas 78751-2321; or(iii) by fax to (512) 438-363261.(C) A program provider must, with its request for an informal review: (i) submit a concise statement of the specific findings it disputes;(ii) specify the procedures or rules that were not followed;(iii) identify the affected cases;(iv) describe the reason the findings are being disputed; and(v) include supporting information and documentation that directly demonstrates that a disputed finding is not correct.(D) DADS does not grant a request for an informal review that does not meet the requirements of this subsection.(2) Upon receipt of a request for an informal review, the Trust Fund Monitoring Unit Manager coordinates the review of the information submitted. (A) Additional information may be requested by DADS and must be received in writing by U.S. mail, hand delivery, special mail, or fax in accordance with paragraph (1)(B)(i) - (iii) of this subsection no later than 15 days after the date the program provider receives the written request for additional information. If the 15th day is a Saturday, Sunday, national holiday, or state holiday, then the first working day after the 15th day is the final day the additional information is accepted.(B) DADS sends its written decision to the program provider by certified mail, return receipt requested. (i) If the original findings are upheld, DADS continues the schedule of deficiencies and requirement for corrective action.(ii) If the original findings are reversed, DADS issues a corrected schedule of deficiencies with the written decision.(iii) If the original findings are revised, DADS issues a revised schedule of deficiencies including any revised corrective action.(iv) If the original findings are upheld or revised, the program provider may request an administrative hearing in accordance with subsection (b) of this section.(v) If the original findings are upheld or revised and the program provider does not request an administrative hearing, the program provider has 60 days from the date of receipt of the written decision to complete the corrective actions. (I) If the program provider does not complete the corrective actions by that date, DADS may impose a vendor hold. If DADS imposes a vendor hold, the program provider may request an administrative hearing in accordance with subsection (b)(5) of this section.(II) If the failure to correct is upheld, DADS continues the vendor hold until the program provider completes the corrective action.(b) Administrative hearing. (1) The program provider must submit a written request for an administrative hearing under this section to: HHSC Appeals Division, P.O. Box 149030, Mail Code W-613, Austin, Texas 78714-9030.(2) The written request for a formal hearing must be received within 15 days after: (A) the date on the written notification of the report of findings described in section § 261.262(d) of this chapter; or(B) the program provider receives the written decision sent as described in subsection (a)(2)(B) of this section.(3) An administrative hearing is conducted in accordance with 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act).(4) No later than 60 days after a final determination is issued as a result of an administrative hearing requested by a program provider under § 261.262(e)(2) of this chapter or subsection (a)(2)(B)(iv) of this section, the program provider must complete any corrective action required by DADS or be subject to a vendor hold on payments due to the program provider under the provider agreement until the program provider completes corrective action. If DADS imposes a vendor hold, the program provider may request an administrative hearing in accordance with paragraph (5) of this subsection. If the failure to correct is upheld, DADS continues the vendor hold until the program provider completes the corrective action.(5) If DADS imposes a vendor hold under § 261.262(g) of this chapter, subsection (a)(2)(B)(v) of this section, or paragraph (4) of this subsection, the program provider may request an administrative hearing within 15 days after receiving notice of the failure to correct and the vendor hold. The administrative hearing is limited to the issue of whether the program provider completed the corrective action.26 Tex. Admin. Code § 261.263
Adopted to be effective November 4, 2013, 38 TexReg 7724; Transferred from Title 40, § 9.263 by Texas Register, Volume 45, Number 35, August 28, 2020, TexReg 6127, eff. 10/1/2020