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Effective Date: 
2/2015

Documents

 

Instructions

Updated: 2/2015

 

Purpose

Form 4800-D serves as:

  • A document for Health and Human Services Program Support staff to record information to be entered in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearing system in order to notify the Texas Health and Human Services Commission (HHSC) Fair Hearing Division that an applicant or individual is dissatisfied with an agency action and has requested a fair hearing.
  • Documentation of the basis for the appellant's dissatisfaction.
  • Notification to the Fair Hearing Division:
    • that the appellant has an authorized representative or legal counsel.
    • of the names of individuals outside the program or agency area who are to be notified of the date and time of a hearing.

 

Procedure

When to Prepare

The program representative prepares Form 4800-D when an applicant or individual wishes to appeal an agency action. If additional room is needed to list all "Other Participants," the program representative completes and attaches Form 4800-DA, 4800-D Addendum.

The program representative must ensure that information on Form 4800-D is sent to the hearings officer through TIERS within five calendar days from the date the request for appeal is received by the agency. If the information is sent to a data entry representative, the program representative must complete and send Form 4800-D within three calendar days of the date the request for appeal is received in order to allow two days for data entry.

Transmittal and Copies

Complete Form 4800-D to document all relevant information to be entered into the TIERS Fair Hearings and Appeals system. Send Form 4800-D to the designated data entry representative for the program area. For programs with direct access to the TIERS Fair Hearings and Appeals system, the information may be entered directly. Send one copy to the program area supervisor.

The TIERS Fair Hearings and Appeals system will automatically alert the HHSC Fair Hearing Division of the request for a fair hearing. The Fair Hearing Division will implement the fair hearing process by sending HHSC Form H4800, Fair Hearing Request Summary, to each of the following:

  • the appellant, along with the original Form H4803, Notice of Hearing;
  • the appellant's representative, if appropriate;
  • the agency representative and supervisor entered in TIERS; and
  • persons listed as other participants, including individuals outside the program agency area scheduled to participate in the hearing (for example, Office of Attorney General, the provider agency).

Form Retention

Retain a copy of Form 4800-D for the case record.

 

Detailed Instructions

To: Data Entry Representative (DER) — Enter the name of the designated data entry representative who enters the information into the TIERS Fair Hearings and Appeals system.

From: Program Representative's Name — Enter the name of the individual submitting the form. The hearings officer contacts this person if additional information is needed.

Region — Enter the two-digit number of the region that made the appealed decision.

Unit No. — Enter the two-digit number of the unit that made the appealed decision.

New — Check to indicate if this is a new appeal.

Maintain — Check to update the agency representative information. The agency representative information is the only information that can be changed once the appeal has been submitted.

Date Sent to DER — Enter the date Form 4800-D was sent to the data entry representative.

Date Received by DER — The DER enters the date Form 4800-D was received.

Appellant's Name — Self-explanatory.

Appeal ID No. — The program representative leaves blank. The DER enters the number after the information is entered in TIERS and the appeal number is assigned.

 

1. Information for Add New Appeal

A. Type of Action — Always check non-TIERS.

B. Agency Action Date — Enter the date the notice of adverse action is sent to the applicant or individual.

C. Non-TIERS Criteria Individual No. — Enter the appellant's individual identification number. This is the client number, Medicaid number or individual number assigned through TIERS or the Service Authorization System (SAS). This number is the only number used as the identification number for this individual throughout the form. Where the system asks for the legacy or eligibility determination group (EDG) number, enter this individual number.

 

2. Appeal Information

A. Method of Appeal Request — Check the box that best describes the medium through which the agency learned of the appellant's request to appeal: Email, Fax, In Person, Mail or Telephone.

B. Appeal Request Date — Enter the earliest date the appellant expressed dissatisfaction with the action. This may be the date the agency receives a telephone call from the appellant or the date a form is signed by the appellant requesting the appeal.

C. Appeal Receipt Date — Enter the date the agency learned of the request. This may be the same date as the appeal request (if telephone contact or in person) or the date signed correspondence was received in the office.

D. Action Effective Date — Enter the date the decision or action was or will be effective.

E. Hearing Telephone Contact No. — Enter the area code and telephone number of where the appellant can be reached for the hearing.

F. Other Information

MCO — If the appellant is in a Managed Care Organization (MCO), mark this box and identify the name of the organization from the list below. The drop-down menu includes:

Amerigroup S+P
HealthSpring S+P
Molina S+P
Superior S+P
United S+P

TMHP — If the request for the hearing is due to denial of Medical Necessity (MN) through Texas Medicaid and Healthcare Partnership (TMHP), check "Yes". If not, check "No".

Provider Agency — Enter the name of the appellant's provider agency, if applicable.

Under 21 — Mark Yes if the appellant is under age 21 or No if the appellant is 21 years or older.

MEPD Action — Mark Yes if the root cause of the appeal is due to Medicaid for the Elderly and People with Disabilities (MEPD) action or No if it is not.

 

3. Appellant Details – Programs

A. Program – Community Care — (This is only choice for programs).

B. Type of Assistance – TOA — Mark the box by the specific HHSC program for appealed action. For CCAD enter the specific service (for example, for Community Care for Aged and Disabled (CCAD), mark the box and enter Emergency Response Service, Primary Home Care, etc.).

C. Issue Code — Enter the reason for the agency action from the drop-down list below.

H01-Income

H61-Home Mod and Adaptive Aids

H02-Resources

H71-Ambulance

H03-Transfer of Resources

H72-Dental/Orthodontics

H04-Household Composition

H73-Limited Program

H08-Unable to Locate

H74-Durable Equipment

H11-Missed Appointment

H75-Private Duty Nursing

H12-Failure to Furnish Information

H76-Therapy/Rehabilitive Services

H14-Voluntary Withdrawal

H77-Payment Denial

H20-Disability

H78-Surgery/Procedures(MRI/Injections)

H53-Form 2060

H79-Not a Benefit/Not Subject To

H54-Hours of Service

H80-End-Stage Renal Disease (ESRD)

H56-No Unmet Need

H99-Other

H57-Medical Necessity

N73-Limited Program

H58-Risk Criteria

N76-Therapy/Rehabilitative Services

H59-TILE/RUG

N79-Not a Benefit/Not Applicable Issue

D. Summary of Agency Action and Citation — Enter a brief summary of the action taken and the applicable handbook references and/or rule citations on which the action was based.

Is individual eligible for continued benefits? — Mark Yes or No.

Appeal requested timely for continued benefits? — Mark Yes or No.

Is there a good cause for non-timely? — Mark Yes or No.

Has household waived continued benefits or services? — Mark Yes or No.

Date continued benefits waived — If benefits were waived, enter the date the appellant informed of the decision to waive benefits or services.

 

4. Appellant Information

A. Appellant Information — Enter the appellant's name, date of birth, Social Security number, and area code and telephone number.

Is interpreter needed? — Mark Yes or No.

Interpreter Language — If Yes, enter the language. The DER will select the language from a drop-down list.

Special Accommodation? — Mark Yes or No.

Special Accommodation Type — If Yes, indicate the type of accommodation from the list below.

FF - Face-to-Face

TDD - Hearing Impaired/TDD Line

VI - Visually Impaired

B. Physical Address

Street No., Street Name/Rural Address — Enter the street number, including fractions, apartment number, direction (that is, North, South, East or West) and the street name; or enter the rural address.

Street Type — Enter the street type, if applicable.

Dwelling Type — Enter the dwelling type, if applicable.

Address Line 2 — Enter additional information for the address, if applicable.

County — Enter the name of the county.

City — Enter the name of the city.

State — Enter the state.

ZIP Code — Enter the ZIP Code.

Address Validation Required — This is always No for Non-Tiers cases.

C. Mailing Address — Enter the mailing address only if it is different than the physical address.

 

5. Appellant Representative

A. Appellant Representative Type — Check the appropriate box for the representative type. If the appellant has a legal representative, enter the information here.

B. Appellant Representative Name — Enter the name and area code and telephone number where the representative can be reached. Include the name of the organization/company the person represents, if appropriate.

Is interpreter needed? — Check Yes or No.

Interpreter Language — If Yes, enter the language.

Special Accommodations? — Check Yes or No.

Special Accommodation Type — Enter the special accommodation type needed. (Refer to the menu in Item 4A.)

Permission to Release Information — Enter Yes or No. Note: A signed release of information must be on file.

C. Mailing Address — Enter the representative's mailing address where information about the hearing can be sent.

 

6. Agency Representative

Are you an Office of Eligibility Services (OES) Texas Works or MEPD employee?  If this is a Medicaid for the Elderly or People with Disabilities (MEPD)/Texas Works (TW)-related appeal, select "Yes" to this question. You are actually responding to this question on behalf of the Centralized Representation Unit (CRU), so "Yes" is the correct response. On the Agency Representative page, select "Yes" in the drop-down menu. Failure to answer "Yes" to this item will result in CRU not being notified of the hearing.

The agency representative is determined by the type of action being appealed. If the appeal is for a program/service decision, the name of the case manager or program representative is entered. Enter the name as it appears in Outlook.

If the appeal is for a Medical Necessity, then the name of the Texas Medicaid & Healthcare Partnership (TMHP) representative is entered. This representative's information must be entered by using the Model Office Resources (MOR) search feature in TIERS.

If the appeal is for a financial eligibility decision made by the MEPD or TW specialist, the name of the CRU representative is entered. This representative's information must be entered by using the MOR search feature in TIERS.

A. Agency Representative Name — Enter the name of the agency representative who will attend the hearing. Enter the representative's area code and telephone number.

B. Office Mailing Address — Enter the representative's office mailing address. Include the street number, fraction, suite number, direction, street name and street type (if applicable). Enter the agency representative's mail code.

Email Address — Enter the agency representative's email address.

 

7. Agency Representative Supervisor

A. Supervisor Name — Enter the name of the agency representative's supervisor and their area code and telephone number.

If the agency representative is located through the MOR search feature, then these fields will automatically populate.

B. Office Mailing Address — Enter the supervisor's office mailing address, including the street number, fraction, suite number, direction, street name and street type (if applicable). Enter the agency supervisor's mail code.

Enter the agency supervisor's email address.

 

8. Other Participants

Enter the name of any other participants who are required or have requested to attend the fair hearing. This includes any additional program staff required to attend a hearing.

If the case manager or program representative was not listed as the agency representative, his name must be listed here.

For each participant listed, enter the name, organization and title. Example: John Smith, case manager.

Enter the participant type for each name. The selection for participant type is:

Agency Witness

Appellant Witness

Observer

If the participant will need an interpreter, enter the language.

If the participant will need a special accommodation, enter the accommodation type needed. (Refer to the menu in Item 4A.)

Enter the participant's mailing address. Include the county and the participant's area code and telephone number. For agency staff, enter the mail code.

Enter the participant's email address.

List additional participants on Form 4800-DA, 4800-D Addendum.

 

9. Additional Comments

Enter any additional information that may be relevant for the hearings officer regarding scheduling or conducting the hearing.

DER Signature — The designated data entry representative signs the form.

Date Entered — The designated data entry representative enters the date the information is entered into the TIERS Fair Hearings and Appeals system.

Appeal ID No. — The designated data entry representative records the Appeal ID No. assigned to the appeal from TIERS. This number is also entered on Page 1, Line 2.