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Effective Date: 



Updated: 9-2011


To document a region's request for review of a fair hearing decision. This procedure does not apply to managed care programs.


When to Prepare

Regional staff prepare when staff determine a fair hearing decision conflicts with HHSC policy or a clear error of law or fact has been identified.

Number of Copies

One original and a copy for regional files.


This form is transmitted per regional procedures to Community Services Policy (CSP), State Office, for review of the fair hearing decision. The CSP Unit manager (or designee) reviews the request and returns the form to the regional director upon completion of the review.

A copy of the fair hearing decision letter must be attached to Form 1590.

Form Retention

This form is kept in regional files.

Detailed Instructions

To Community Services Policy Unit Manager, State Office — Enter the CSP Unit manager's name.

Date Submitted to State Office — Enter the date the form is mailed to CSP.

Date of Hearing Decision — Enter the date of the hearing decision.

From Regional Director — Enter the name of the regional director.

Area Code and Telephone No. — Enter the regional director's area code and telephone number.

Applicant/Individual/Member Name — Enter the individual's name.

Identification No. — Enter the individual's identification number. This is the Medicaid number or the individual number assigned through the Texas Integrated Eligibility Redesign System (TIERS) or the Service Authorization System (SAS).

Region — Enter the number of the region requesting review of the fair hearing decision.

hearings officer Name — Enter the name of the hearings officer who rendered the hearing decision.

Date of Hearing Decision — Enter the date of the hearing decision.

Description — Enter a description of the case action taken by the case manager, the decision of the hearings officer, points of disagreement (including conflicts with HHSC policy) and pertinent policy citations to support the request for review.

Was information submitted during the hearing that supports your position? — Check Yes or No, as applicable. If the response is No, the fair hearing exception request cannot be submitted. Only information presented at the hearing can be considered.

Was this information orally offered as evidence during the hearing? — Check Yes or No, as applicable. If No, a fair hearing exception request cannot be submitted.

What policy supports your position? — Enter citations from the applicable policy handbook or Texas Administrative Code to support the position.

How is this decision contrary to policy? — Referring to the citations listed above, explain how the fair hearings officer's decision contradicts policy.

Community Services Policy (CSP) Response to Region — This section is used by the CSP unit manager (or designee) to document the decision made after review of the hearing decision by CSP staff and, if appropriate, fair hearings and legal staff.

Date — The CSP Unit manager (or designee) enters the date the response is forwarded to the regional director.

Decision — The CSP Unit manager (or designee) enters the decision regarding agreement or disagreement with the hearings officer's decision, and notes any other actions being taken by the CSP Unit manager (or designee).

Actions Required by the Region — The CSP Unit manager (or designee) enters instructions regarding any necessary case actions as a result of the fair hearings exception review process.

Additional Comments — Enter additional comments as needed.