Revision 12-4; Effective December 3, 2012
During fair hearings in which medical necessity (MN) determination or resource utilization group (RUG) value change or calculation is in question, such as fair hearings due to MN denials or reduction in services due to a decrease in the cost limit, Department of Aging and Disability Services (DADS) staff present information to the hearings officer and applicant or individual to explain the MN determination or RUG value calculation process. Regional staff present these processes to the hearings officer and applicant or individual by using the script below.
The MN determination and RUG value explanation scripts are for regional staff to use during fair hearings for MN denials or a change in the RUG value. Regional staff must provide testimony utilizing the script to give a general explanation of how the RUG value is determined.
Texas Medicaid & Healthcare Partnership (TMHP) is the DADS agency representative in fair hearings for MN denials. Regional staff must ensure adequate testimony is provided regarding the processes and entities involved in making the MN determination. The script will assist in providing this information. During fair hearings in which the validity of the MN is in question, regional staff have the option of utilizing the script since TMHP will present information on the Medical Necessity and Level of Care (MN/LOC) Assessment. TMHP staff do not participate in fair hearings to explain RUG value differences for an applicant or individual.
Regional staff should always include the script with the agency evidence packet submitted to the hearings officer and the applicant or individual prior to the fair hearing if the fair hearing is related to either the MN determination or RUG value calculation.