there's also a box just to the right of
the question box called web links and
means our resources our presenters today
may be referencing in the presentation
we have live captioning as well as our
ASL interpreter on screen and our
presenters will be by audio only we'll
go ahead and turn it over to Peter
hopper who is our moderator for today's
event Peter hi thanks Matt thanks
everyone for joining us today
this is Peter Hoffer I'm a senior
litigation attorney here at Disability
Rights Texas over the past 17 years or
so I've represented about 250 children
and Medicaid Appeals
I've also litigated several federal
lawsuits against Texas Medicaid so all
of us presenting have experience with
children's Medicaid Appeals I'm joined
by Terry Anstey another one of our
health care lawyers Terry is also a
registered nurse so he brings additional
valuable perspective to the issues we're
gonna discuss today and Hilary Garcia
she's another one of our health care
attorneys and she just represents
children in Medicaid Appeals before we
get started I I want to say that I know
these are very anxious and frustrating
times for parents and families of kids
with disabilities with everything that
Texas Medicaid is doing through managed
care we're going to be discussing how to
prepare for a fair hearing we're going
to try to give you tools to help you do
the best job you can and representing
your child it's sort of a general
presentation but we will have separate
slides on if it's an MD CP denial or if
it's a private duty nursing denials I
wish we didn't have to have this
presentation I wish there were not so
many denials and reductions in services
I also wish that we had more attorneys
that could represent all the children
who need representation but there's only
four of us that
do children's Medicaid cases here at
Disability Rights setting more than that
every week in cases so we wanted to do
something to give parents some some
tools some information they can use if
they have to represent their children
themselves so with that we'll get
started if we don't answer everyone's
questions will probably save them to the
end to make sure we get through the
presentation if we don't get to
everyone's question there'll be a Q&A
email sent out where we will try to
answer all the questions in writing
later there's also going to be some
other materials available a checklist
for preparing for a fair hearing and
some other sample sample letters sample
documents that Teri's put together
also those will also be available so
with that we'll get started and I'll
turn it over to Terry and Hilary okay
great hi this is Hilary we're gonna
start first with the due process
protections for Medicaid beneficiaries I
would like to point out when we begin
with this slide that we will get in a
little bit further in depth within the
webinar about many of these due process
protections so that's just a brief
disclaimer so there is the right to have
a fair hearing at a reasonable time date
or place as a little bit further parents
do have the option to request a
continuance a big thing for this pie
particularly is the case file most time
parents will receive the evidence packet
and might not notice that within the
actual letter with their appeal rights
they have that notification of their
right to request the case file itself
the case file and the evidence packet
are two separate documents and we'll
discuss that a little bit further but
you do have the right to request and
review the case file prior to the fair
hearing
I'm also at the fair hearing you have
the right to bring witnesses establish
the facts as pertaining to your child's
case and present an argument without
undue interference also you have the
right to cross-examine adverse witnesses
and cross-examination may seem
intimidating for a lot of parents are
scary in terms of what types of
questions they show but I would say
having talked with many parents and
preparing them through the fair hearing
process that you are prepared and do
have adequate questions to ask during
cross-examination because when we're
preparing for that particular process
with parents they bring up a lot of
issues that if they would have been
doing this on their own they were
absolutely valid questions that they
should raise on cross-examination and
something big also on this slide is the
submitting the evidence before during or
after the hearing
although we will talk about preparing
evidence packet you do have the option
the opportunity to ask that see oh
they're hearing be kept are the actual
record to be kept open so that you can
submit documentation after the fair
hearing itself has concluded so you can
submit that information to the fair
hearing officer again I wanted to
emphasize that particular point because
sometimes when you perceived a fair
hearing you might not have all the
documentation or you might have received
it a couple days before about having
time to submit it to the fair hearing
officer and if you address that
particular document during the fair
hearing you should also have the
opportunity to submit that to the fair
hearing officer so she can review that
documentation before she makes he or she
makes their decision this is Peter I
would also add the
an argument without undue interference I
have listened to some recordings of
hearings where parents did represent
their children by themselves and
sometimes the hearing officers will rush
parents or the agency representatives
will interrupt them and try to rush them
again you have the right to present your
case without interference and just
remind them of that if they start
interrupting or trying to rush you
through the through the hearing this is
Terry I'll take the next slide there a
lot that needs to go into a denial
notice of services or a waiver program
like the medically dependent children
program or MPCP some of that information
first the the letter has to be sent out
ten days before the proposed action date
sometimes it's sent before a way before
that and sometimes it's not you know the
information that needs to be in that
denial notice also is the date that the
fair hearing must be requested to to
receive continued services and also how
many days before you don't have the
right to a fair hearing anymore the the
number that that you can call to request
that for your hearing all right all the
letter also has to say that you can you
or somebody else it doesn't have to be a
lawyer can represent your child in a
fair hearing also talks about that you
have the right to examine the
information before the fair hearing to
determine how the beat and you know the
agency came up with their denial
decision and the circumstances under
which you can have those services will
be continued you can have continued
services during the fair hearing process
the theory behind that the 10-day
appealing with both within ten days to
receive continued services is that the
the agency has to send the denial notice
10 days before the proposed action so if
you appeal before the proposed action
date then you then you then stay that
action
you prevent that action from happening
so that's why you are able to receive
continued services pending the fair
hearing outcome in the next slide these
you know denial notice sometimes you
have a denial notice that says a request
for a certain service was incomplete
this happens sometimes with therapies
denial ot or SPD or private duty nursing
they have to also some some denials rule
they have to state the basis for there's
an I'll action and they have to explain
what policy they use that allegedly
supports that denial action for
incomplete requests I like to add that
you know it may be futile to request a
fair hearing and go to fair hearing on
an incomplete request it's it's it's
going to be difficult to argue in a fair
hearing of that that the denial is
incorrect if the the request for the
service was incomplete it may save time
to just react West the services rather
than go through the fair hearing process
and not have the the services that that
were requested on the on the second
point you know it's important that that
you get the information about why
something was denied the basis for that
denial and the regulation so that you
can test out to determine whether the
agency was actually right or wrong to
determine what box that the agent hit
agency has to stay in during the fair
hearing what they have to prove and the
reasons and the regulations are
important for the hearings officer to
examine oh there's nothing there then
there's nothing to test and there's
nothing that the hearing officer can
look at to determine whether they the
agency was right or wrong next slide
this is this is Peter I just wanted to
mention you know you talked about Terry
the 10 day notice and getting continued
services which is vital for kids I
wanted to make sure parents understood
you should go ahead and
our advice is always to ask for the fair
hearing ask for the appeal ask for your
continued services within those 10 days
you can always withdraw your hearing
prior to the hearing date or even at the
hearing with no with no penalty but if
you miss the 10 day window you won't get
your services continued and the appeal
process can take three or four months so
that's three or four months you'd be
going out with going without services
even if you wouldn't so our advice is
always to appeal ask for a continue ask
for continued services and that gives
you time to make a decision if you want
to go ahead and go through with the
hearing or not
alright the next slide is about
insufficient and I'll notices there
there's an out notices that you know
don't comply with large don't have the
necessary information there are some
denial notices that don't bother to to
give you you know the reasons for the
denial and the regulations that support
it you know if a denial just says that
something's not medically necessary
without further explanation than that
that that doesn't give you what you need
to figure out why something was denied
another example of that is fails to meet
prior authorization criteria that
doesn't tell you what part of the crisis
there may be five six different points
in that criteria if you don't know which
point is the focus of the denial then
then you can't really figure out why
something was denied now some notices
don't state the time limit for
requesting a fair hearing that's
important information for individuals
and if that's not there then people will
be confused on whether they can ask for
a favoring or what the deadline is for
asking for that appeal or fair hearing
and some notices don't know don't tell
you how to request a fair hearing so
that could be a roadblock to getting to
a fair hearing if you get a notice that
just all be necessary or fails to meet
eligibility criteria that's something
the parents should raise with the
hearing officer that's right they can
that up to the hearings officer like at
the beginning of a fair hearing they
can't ask for a special like pre-hearing
conference before the main part of the
fair hearing in order to bring that up
because first parents aren't able to
figure out why something was tonight if
you can't figure that out then then it's
really difficult to actually prepare for
a fair hearing and know how to combat
something that that you that you don't
know what the reasons were for the
denial and then the officer may agree
with with you on that point may ask the
agency to redo their denial notice and
reschedule the hearing for another date
while the 8sc clarifies that so you can
better understand the denial the
hearings officer can better understand
that the denial and you can more
adequately prepare for yourselves for a
hearing okay so MDC P has a different
process in terms of the amount of
letters you will be receiving so
initially you'll receive this pending
denial letter make grants the parents
and the primary care physician the
opportunity to provide additional
information there's not really an
obligation for parents are the primary
care physician to submit information
during this period but it does not hurt
for you to contact the primary care
physician and see if you can send in
information during this pending period
and the primary care physician will
receive a letter just like you did of
the 14-day timeframe to submit
documentation now 14 days is not a long
time so if you do request information
and you receive it after that 14 day
window if you get another letter
thinking that your child is now denied
so the final is in a letter you can
always use that as your evidence at fair
hearing so again it's not really a big
deal if you don't meet that 14 day
window it certainly would help but
there's also the
opportunity for them to continue to deny
versus actually approving but there is
that option so you could get a MN
approved which means team HP would
overturn their denial
so there are there might be issues with
the dena nose itself in terms of you
will receive a final letter from TM HP
if these services if they actually agree
that the decision should still remain
denied but that letter does not have
your appeal right it'll tell you that
you would be receiving a letter from the
program Support Unit now we have heard
from parents that there is an issue with
PS you never sending the letter so they
never have the opportunity to request
the fair hearing and that is something
that we've heard so it does occur but it
also often does not so you will receive
your final denial letter and then you
should receive within two business days
the actual letter from PS you with the
information on how to request your fair
hearing now when it comes to denials
from either traditional Medicaid or
fee-for-service or managed care
organizations they there is a internal
appeal and a fair hearing and in the
past parents were able to skip over an
internal appeal which is an appeal
process I in within the managed care
organization it's a partial proceeding
or you know the fair hearing which is
the impartial proceeding with a HHSC
fair hearings officer they used to be
able to skip over the internal appeal go
straight to a fair hearing but the laws
have changed and now you have to exhaust
your internal appeal before you can get
to a medicaid fair hearing
now the that's the internal appeal it's
sometimes successful you you know it's
really like I said it's it's a partial
proceeding that the mass care
organization is the one looking at their
denial decision again
it's usually a different medical
director that is that it's looking at it
but pretty much usually going to
rubber-stamp what
other medical director did I have seen
some internal appeal process be
successful but it's not typical you also
have to you know request your internal
appeal within 10 days in order to have
continued services during that process
and then if an internal appeal is denied
you you still have to again within 10
days request a medication fair hearing
in order to have continued services
throughout the fair hearing process some
more information about internal appeal
the internal appeal is not really going
to generate an evidence packet like a
fair hearing request does and normally
it's it's sometimes it's a phone call
with a parent or service coordinator and
a managed care organization will call
the parent and maybe get a statement
sometimes I've heard that there isn't
any call at all or the parents don't
have any opportunity to provide any
information and that the medical
director is just looking at the
information again and and making a
decision on whether they were right the
first time again after you get that the
determination if it's a if it's a denial
on the internal appeal and you can ask
for the Medicaid figuring there's
normally it's two separate forms that
you'll get with your original denial
letter on how to ask for an appeal and
then how to ask for a Medicaid for your
hearing there's either two different
processes or two different forms that
can be some kind of sometimes confusing
for parents because appeal and fair
hearing they seem interchangeable but
when they say appeal it usually means
internal appeal and state fair hearing
or Medicaid for hearing is that fair
hearing process we advise you to have
all that filled out and ready to go so
as soon as you get an internal appeal
decision that may be denial again then
you're ready to ask for that medication
fair hearing
okay so there's multiple ways that you
can request a fair hearing what we
encourage is that if you are going to
contact the number provided to orally
request a fair hearing that you have
documentation of who you spoke with the
date and time of the call that way if
there's any issues concerning when you
actually made the request you have that
documentation the same with when you
mail in a request we ask that you get
tracking that way there's that
opportunity that if there's any issues
concerning well you might have been
outside of that 10-day window for
continuation of services which is
vitally important you have something to
say well according to this I sent it in
on this date which was within that ten
day window so we definitely want to make
sure that there's some way that you can
show proof of when you actually made
your request for fair hearing and also
when you request the fair hearing it
does not hurt to also state either
orally or in writing that you are asking
for continuation of services for MDC P
there's usually the form that you can
fill out that they'll send you can also
call in and request the fair hearing as
well so once that PSU ladder has been
received with the information on
requesting a fair hearing when you make
that request they have to refer it to
HHS E which is the Texas Health and
Human Services Commission within five
days that kind of helps with the
timeline of determining when you should
are when your request should be
processed by HHS B there has been issues
where when you request it with PSU they
don't refer it to HHS C so that is just
something to be aware of that that might
be happening if you haven't received
your notice if they're hearing yet this
is Peter the reason we stress making
sure you
keep track of who you talk to when you
talk to them when you requested the fair
hearing or when you send something in
we've had a few cases already this year
where the managed care entity was not
providing continued services and claimed
that the appeal wasn't requested timely
and we were able to show that it was and
the continued services were reinstated
so because you request the hearing from
the managed care entity who then relays
it to HHS see Appeals there's
opportunity for them to sort of drop the
handoff or to not follow through on your
request and so if you can say I talked
to this person at five o'clock on Monday
the first it's helpful establishing that
you did indeed request your appeal
timely and that you should be getting
continued services
you know you've all dealt with Medicaid
for a long time so you can imagine
there's lots of opportunities for there
to be mistakes and so it's better to
protect yourself so that you can prove
that you did request the continuation of
services and appeal within the ten days
so pre-hearing processes before you
continue to the fair hearing something
that I want to stress is continuances so
I know for a lot of parents when they
initially contact us it might be that
they're within a couple days of their
fair hearing so we won't have time to
review all the documentation so we ask
that they ask for a continuance but we
often get you know the feeling that
parents will be timid to ask for more
time but as mentioned you have that
right and to make sure you have all the
information so when I stress the case
file sometimes parents will see the
evidence packet will request the case
file but won't receive it so you do have
a valid request for a continuance
because you don't have that information
and without that information you can't
adequately prepare for the fair hearing
so you do have a basis to ask for
additional time until you receive that
information and have the opportunity to
review it you also have the right to ask
for in-person hearing I think the only
caveat is that it's well be based on the
fair hearing officer to determine if
that if you have a valid reason to
request it most often they believe there
has to be a communication barrier in
order to grant that in-person hearing
but sometimes parents think it's a good
idea for their child to be seen and
that's why they might consider making
that request or if the again kind of
going back to interpreter or translator
might be another reason you would need
to bring that to the fair hearing
officer before fair hearing um I want to
do this is Peter I wanted to answer a
couple questions and again will answer
all your questions either at the end or
in writing but there were a couple on
one asked could you call HHS E appeals
directly to request a fair hearing no
that's just not the system you have to
call the number that's provided that
goes to the MCO and then they relay it
to HHS C Appeals but you did identify it
is a wonder to me why they just don't
have you request your hearing with the
appeals division but they do not do it
that way and then there was another
question about getting denials for
therapy but not getting a denial notice
no that is not lawful providing the
information to the provider is
insufficient it's the beneficiary your
child who has the right has the due
process rights and has the right to
notice providers though you'll learn you
know in nursing cases or therapy or DME
cases they usually get the notice first
because they're requesting the service
and they communicate with Medicaid by
fax so they get a fax and they know that
something's being denied or reduced and
then you get something in the mail a few
days later
so typically parents hear about an
impending reduction or denial from their
provider and
they need to wait a few days to get to
notice if you never get a notice and
that's certainly something you probably
need to call us about to get fixed
because we'd have to call the appeals
division and explain that services have
been denied and no notice was provided
and therefore you lost your opportunity
to appeal and you lost your opportunity
for continued services yes continuances
I know I talked to a parent the other
day who said well we're asking for a
second continuous continuance is that
going to make the hearing officer think
our cases and as good no we asked for
continuance is all the time sometimes we
cannot get the case file which we're
going to talk about what is the case
file but I've had cases where I just
could not get the case file from the
agency and I asked for six or seven
continuances because I cannot go ahead
with a hearing and make it a fair
hearing if I don't have all the
documents that I'm entitled to so if you
need a continuance because of the
scheduling a doctor you need more
medical more time to get gather
additional medical information your
child has a surgery you know those are
all good cause reasons to ask for a
continuance so don't be shy about it
they typically give the first one almost
automatically for the reason that you
need the case file or you need
additional time to prepare the more you
get the harder it is to get them because
they do want to get the hearing held so
the first step you will receive your
notice of fair hearing and I would like
to say that usually parents will just
focus on the first page that gives them
hearing officer the date and time and
something that's really important is the
fair hearing summary so you'll get this
small packet of information and the fair
hearing summary will show they'll have
questions on when you maybe appeal and
when the actual action
that is being either reduced or denied
with to take place and that's how
they'll determine if your child has
continuation of services so if that date
is incorrect or if the box is incorrect
Lee place as no your child is not
entitled to continuation of services
then you'll have that issue that you can
address as soon as you receive that fair
hearing notice so rather than waiting
until either your nursing agency or your
see verification that they're going to
go off of the reduced number of hours if
it's nursing or visits if it's therapy
you can kind of get ahead of that if you
know on that form that there is an issue
that you can address but also after you
get that information you should receive
a copy of the the evidence packet which
will include all the exhibits policies
and regulations that Texas Medicaid
utilize to make their determination
whether it's a denial or reduction
services something that is big is the
Phoenix notes or the eternal note so
we've mentioned that the denial notices
can be inadequate they can be vague or
just state lack of medical necessity
there's not a way for you determine
exactly why they made their decision but
the Phoenix notes might help a little in
determining just what the medical
directors looked at or what they relied
upon in making their determination and
that can help as you prepare for fair
hearing all right there sometimes can be
issues with the actual evidence packet
that you that you in some cases don't
receive in a timely manner you know
sometimes people our parents are not
receiving it at all before a fair
hearing date or they're receiving it we
then you know maybe just a short period
of time before the fair hearing like a
week or a few days that's happened a few
times recently was
my clients if if a fair hearing packet
is not received before the figuring you
still need to call in to the hearing at
the scheduled date and time and tell the
hearings officer that you never received
it that way they can make an reschedule
the hearing to allow the text medication
to send you that packet like they were
supposed to if you received it like a
week or a few days in advance and that's
still not enough time for you to prepare
for your child for your hearing that's
another good reason to ask for the fair
hearing to be rescheduled and if the
denial does that that's not good enough
you know without the information that
they that they received you won't even
be able to get that help from the
internal notes that that Hilary just
mentioned to determine you know how they
came up with denial decision or
reductions a decision let me stress
never miss a Medicaid fair hearing if
it's scheduled and you have to call in
to the fair hearing okay
don't miss it and assume without
confirmation that fair hearings been
rescheduled always call in unless you
unless you hear otherwise from the fair
hearing office and don't be afraid to
request those continuances I think we're
stressing that pretty well if you feel
like that you need more time to gather
information and prepare for your child's
fair hearing don't be afraid to ask for
that all right there could be issues
with the case file as well know the case
file is all the information that's going
to be in your child case file for Texas
Medicaid not just related to the
reduction or denial and services that
you're fighting with Texas Medicaid
about now the case files not the
evidence packet the evidence packet is
specific to be the issue that you're
going to be dealing with at the fair
hearing but you can ask the managed care
organization for the case file usually
you ask the hearings officer for and
then the hearings officer gets with the
managed care organization ask the man
managed care organization to send to you
the case file the MCO has to prepare
that and send it to you it might be kind
of long depending on how much you know
how long your child's been in Medicaid
what kind of services they they've
utilized you know you want to go through
all those
documents you go through that case file
of determine if there's anything in that
case file that you may able to utilize
in your own hearing packet that you're
going to put together for your side of
the fair hearing now in reviewing the
evidence packet the the information you
know it's going to have some documents
that you may have already looked at you
know the information from the nursing or
therapy or DME provider like Hillary was
saying look at those internal notes
written by the managed care organization
to determine you know how they how they
came up with their decision are they a
transparent and how they got to their
denial decision or the reduction
decision make sure you you highlight all
the names of the individuals the players
you know the medical directors the
nurses determine you know when they did
certain things you know if you like in a
private duty nursing case they're
supposed to you know notify your doctor
you know the managed care organizations
medical director is supposed to talk
with your doctor before they make a
denial decision did they do that and if
they did did they do it after they
already made a denial decision or did
they do it before did they call them and
then not give them an adequate amount of
time to call them back in order to have
like a peer-to-peer call those that's
important information that you can bring
up during a fair hearing okay Terry I
wanted to mention a couple more things
we between the evidence packet and the
case file so the case file again that's
a bigger set of documents than the fair
hearing evidence packet I think another
way for y'all to think about the
evidence packet that you get from the
hearing officer that is the agency or
the managed care entities evidence
that's what they're going to use to try
and win the fair hearing so that is the
evidence that they've submitted that
they have to submit and that they also
think is helpful to them the case file
is going to have additional information
so I know we had some questions
so let's take a case for example the
evidence packets going to have the most
recent requests for private duty nursing
and the denial or reduction and then the
regulations or rules that they think
support that decision it'll have the
request the plan of care and all that
information the case file will have all
of the prior requests for private duty
nursing this is true with MD CP it would
have the prior assessments for an MD CP
that were approved for eligibility so
that's why these are important because
you can show the hearing otherwise the
hearing officer is looking at this
request for nursing came in it got
reduced or denied you can show them hey
here's six prior requests for private
duty nursing that look essentially the
same my child's condition is essentially
the same the plans of care are
essentially the same I don't understand
why the reduction is occurring so those
are the kind of documents in the case
file that you're gonna want to see so
you write the hearing officer a letter
you say I need a continuance I need more
time I need a new hearing date and by
the way I'm entitled to the case file
I need the Texas Medicaid to send me my
child's case file before the hearing and
if you don't get it then you can ask for
another continuance and another
continuance till you get it but in that
you know you can show prior approvals
for the same amount of nursing or
private prior eligibility findings so
it's very important the case file versus
the evidence packet but the evidence
packet is what the agency or the health
plan is going to use to try to win to
win the hearing and uphold their
decision okay options after reviewing
the evidence packet now the example we
use here is you know what if the what if
the evidence or the denial letter that
you were seeing focuses on an issue that
that maybe could be corrected before a
fair hearing or with a request sometimes
in a physical therapy case maybe the
goals weren't written correctly and the
managed care organization pointed that
out in their denial letter you know is
it
you know should you go to the fair
hearing well that you know it all
depends of course you know you could
withdraw but if and try to fix the issue
but that there's that might not be a
good idea because the fair hearing that
you're requesting may be keeping
continued services in place during the
fair hearing process and if you withdraw
then you lose those continued services
say it was a reduction from three times
a week for physical therapy to one time
a week of physical therapy and you go
down to one time a week of physical
therapy while the therapy agency fixes
the issue tries to re-request what you
could also do is just ask for a
continuance get a nuclear hearing date
while the physical therapist fixes the
issue and then maybe it can get resolved
before the fair hearing date and then if
it gets resolved and you withdrew your
request for the fair hearing then you
will don't lose the continuing services
because perhaps the physical therapy
provider fix the issue and you're back
to three times per week approved by the
managed care organization these kind of
have to figure that out on whether or
not you want to go forward with your
hearing and the timing of trying to fix
the issue before the fair hearing
okay so the mdc-t evidence packet in
case file the evidence packet will
contain the started screening and
assessment instrument or the SKS AI most
parents often remember that visit that
they have but have never physically seen
the form so what we have seen from our
clients with NB c-- p is that they'll
notice errors or omissions in their
child's s KS AI which it will be
important for you to comb through that
assessment and either highlight or note
where all the errors or omissions are so
you can use that and bring that up at
fair hearing also which will be included
in the information that's provided after
this presentation there are certain
sections that t MHP looks at and we have
a paper that has all those sections that
t MHP utilizes to make their
determination because the s KS i form
itself has many sections but not all of
them are focused on in terms of finding
medical necessity there are certain
sections and those sections should be
your focus especially if in those
sections you see errors or omissions as
peter mentioned the case file will
contain the past assessments just one
kind of caveat that we have seen in
preparing these types of cases the dads
nurses that had done that or excuse me
was doing the assessments prior to the m
ce o--'s doing them they might have
included I guess just bad notes or they
copy and pasted throughout the years
even though your child's condition might
have changed a little in terms of their
needs so that's something you will have
to look at and consider if you're
thinking should I include the past
assessments or not
sometimes the information will be
accurate and it is the decision that you
will include all of the past assessments
but if you see those issues so if you
know have your child who had seizures or
very early on in life but as he or she
aged their seizures were no longer a
problem but that was included throughout
each assessment that your child was
continuing to have seizures when that
wasn't the case because the dad nurse
just copy and pasted then that might be
something you could potentially have to
address at fair hearing if you included
those past assessments for the pdn
evidence packet and again you will see
things you might have already seen in
terms of the prior authorization
requests that you might have signed with
the nursing agency so a lot of parents
when they see that evidence packet
they'll think well this is a lot of
things I've already seen I've already
reviewed especially if there's nursing
notes also included but the prior
authorization request plan of care nurse
and addendum are all things you might
have seen and that will be included in
the evidence packet but again it should
include
information that the nursing agency
might have sent in during the appeals
process so during that internal appeal
your nursing agency might have submit
let's say two weeks worth of nursing
notes letters from your doctor if they
had the opportunity to request those and
maybe Mars met the medication
administration seizure logs all that
information and that should be included
in your evidence packet if it's not it
might come out in your case file which
again stresses the importance of
requesting and reviewing the case file
because if it's in the case file but not
in the evidence packet then the fair
hearing officer won't have the
opportunity to review that information
it should be included if it wasn't
enduring the eternal appeal process
because it went into their final
determination but we've have seen where
it hasn't
included especially with the newer
managed care organizations I think we've
seen that issue with Aetna where the
agency said they submit information
during the appeals process but it was
not included in the evidence packet
itself then we have stressed the
importance of the Phoenix notes to look
at them and see if you can gauge a
little bit better why they they made
their determination whether it be the
reduction or the denial also it's
important to look at and review the
actual regulations and rules that they
include in their evidence packet certain
MC O's managed care organizations will
have their own guidelines and sometimes
their guidelines are extremely bad
because they will include links and
access to information that they won't
include so for example we've seen that
with Aetna they'll include this
three-page pdn guideline that looks like
it's hyperlinked to other information
but you don't have that information so
it prevents you from knowing well what
is this definition or what is that book
or article they're citing that we can't
see and it does pose a problem and
something you can bring up to the fair
hearing officer that the guideline is
lacking of the additional information
now gathering your evidence for the fair
hearing this is when you start to build
your evidence consider requesting some
of these documents to start building
your case for your child you know
progress notes and test results and
medical history from your child's
primary care physician or other
specialist pulmonologist
gastroenterologist neurologist all those
different apologists you know you want
to you want to make sure that you get
you know at least within the last six
months to a year any good information
from those doctors you may request
medical documentation about emergency
room visits or hospital stays that kind
of information would be compelling for a
hearings officer to see and you know you
may get some additional info
Meishan from the nursing provider as a
therapy provider that wasn't looked at
by the managed care organization and
coming up with their denial or a
reduction decision that may be nursing
notes some for whatever reason some
managed care organizations are just
failing to look at nursing notes before
they actually make a denial decision so
you may be able to get some of those
nursing notes and have them in a packet
that you put together that shows look
you know the managed care organization
is incorrect see this is all that's
being done for my child seizure logs
suction logs medication administration
records and then consider getting
letters of medical necessity or support
from your child's doctors and
specialists that kind of information
could be compelling to two to robust the
managed care organizations denial or
reduction you want to review all the
evidence that you are thinking about
using as it comes in to you after you're
requested you get it you review it and
we review your letters of medical
necessity we all know sometimes doctors
don't have a lot of time to do the job
on some of those letters of medical
necessity you may get something that's
kind of lacking you may get something
that's a small paragraph that just says
what the diagnoses are it doesn't really
it's not really helpful doesn't really
you know add a lot to your child's case
we suggest that use that as a litmus
test for determining what documents
you're going to include in your evidence
packet I mean does it add something does
it
add information not already present it
somewhere else I mean resist the
temptation to just include information
just for the sake of including it in
your hearing packet if it doesn't help
or doesn't add anything or it's
repetitive consider leaving it out you
don't want to drowned out all your
impactful documents with stuff that
doesn't really add to your child's case
so keep that in mind when you're putting
together your own evidence packet be
organized and if you're awaiting
additional documents you know we're
going to discuss that you know like
Hilary said earlier you can you can ask
that the fair hearing be you know kept
open for a certain amount of time while
you wait for those documents after the
fair hearing and it can send them into
the hearings officer for their review
um this is Peter we just had a few
questions and I just wanted to clarify
the the PowerPoint and other materials
are going to be available after the
presentation to download because I know
we're giving you a lot of information in
a short time so there's going to be the
PowerPoint there's a the prior
presentation about what to expect at a
fair hearing there's a checklist and
there's some sample letters of medical
necessity sample letters to hearing
officers things like that so that'll all
be available for you to have I guess the
first thing we do when we're thinking
about our evidence or evidence we're
going to use in support of the child's
case you know letters from the
physicians and specialists are probably
the most important and we start on those
early because you know trying to get
doctors to write or sign letters that
takes time and so but like Terry said if
you're at the hearing and you're waiting
on a swallow study or a letter from a
doctor you can ask to keep the record
open and get that added in later but
we'll talk about that in a little bit
this is a slide specific to you
preparing for a private duty nursing
fair hearing you know these are
important points important things to
look at you need to you know understand
the definition of professional nursing
which is in the Texas occupation code
and we have a link there that talks
about professional nursing you know the
things that are included in that or
assessment interventions medication
administration also you know understand
what the definition of correct or
ameliorate means that's the medical
necessity criteria for private duty
nursing in Texas the managed care
organizations like to forget that the
information that is in Chapter 363 of
the Texas Administrative Code about
private duty nursing services there's a
lot of helpful information there as well
a lot of what's in that text
administrative code rules were taken out
you know a settlement agreement you know
that that peterhof ER worked
for fifteen or sixteen years Alberto in
many of you have heard of it
a lot of that information from the
settlement agreement was placed in these
at the sex Administrative Code rules at
chapter 363 good information about you
know span of time that the Georgian
managed care organization has to approve
the services that occur over the span of
time you know that the nursing occurs on
the span of time in a 24 hour day so if
the nursing services occur over eight
hour period then they should be
receiving eight hours per day of Nursing
there's information about you know the
PDN definition and that there's good
information in there about how what HHS
see can't do or the managed care
organization can't do and one of those
main points is they can't reduce privacy
view nursing if there's been no decrease
in the nursing needs your child's
nursing needs so that's good information
to point out to a hearings officer that
maybe the managed care organization
didn't take those things into
consideration also the PCAs manual this
is the manual that pertains to pcs or
attendant care for children in Texas
Medicaid a lot of times what's helpful
in here is that the PCs program in the
PCAs manual points out a lot of things
that the PCs program considers to be
nursing care so a lot of times the
managed care organization will try to
say well that's not nursing and they'll
try to punt it to the attendant care
program but the attendant program says
no that's we have it in our manual that
that is that that may be considered
nursing and usually is nursing an oxygen
administration seizure monitoring and
and and treatment and and nebulizer
treatments those types of things but the
PCs program is pointed out is nursing
okay so review the denial notice again
and this is a suggestion that I think
you should take after you start
preparing your evidence packet and have
all that information it does not hurt
for you to look at and see the denial
notice reasoning again are the medical
directors Phoenix notes I would suggest
that when looking at the denial notice
the second time to think especially when
it comes to maybe a reduction not or
even an outright - now if there's
information that they include especially
when it comes to nursing so these
typical things your child has are they
omitting anything else so if they say
has g-tube feeds but they don't mention
assessments the daily assessments they
need whether it be seizure assessments
and the like so there might be things
that the state our our nursing as an
example but that there's additional
things that they're just leaving out and
that's the information that you would
need to get to address to the fair
hearing officer so in looking at it just
give it a quick second review and think
are there other supportive documentation
that I need outside of just countering
the information in the denial notice and
then also I want to stress the
importance of if the child has an
upcoming appointment it might help if
you drafted a letter or if they we're
thinking about dropped in a letter to
discuss it at your child's appointment
and take the time to go through what's
going on with the either the primary
care physician or the specialist that
your child is seeing and see if they can
draft a letter maybe right there in the
office or look at something you drafted
and makes corrections right there and
then and it's an easier way to make sure
you'll get the information that you need
so preparing your evidence packet I
think the importance is to have this
cover page you'll notice when you
receive the either the managed care
organizations or team hp's evidence
packet that they'll have a cover page of
the documents included in their evidence
packet and sometimes what it's
frustrating is that they won't have
their page numbers or their documents
with the number the put the page number
excuse me on the bottom so they might
say then the cover page pages 1 through
5 is this but they won't have something
to where if you're tabbing you can
readily figure out what page is this
without looking at and counting each
page and so you get to the necessary
page so we stress that you need to
include page numbers so that way when
you're providing testimony at fair
hearing if you're referencing a page you
can easily say on page 28 of my
submission for a fair hearing and then
go through the documents that way
everyone's on the same page and can be
looking at it while you're actually
discussing it
so create a guide have the page numbers
and then just to click suggestion in
terms of if your cluding a lot of your
child maybe progress notes or visits
consider having them in in order based
on date so maybe the most recent visit
the most recent information and if
you're going to me to include the past
information as well have that towards
the end or depending on if the more
important informations on the end just
consider how you might be utilizing that
document in terms of how you're going to
organize it yeah and this is Peter and
you're gonna have to submit your
evidence packet to the hearing officer
who then gets it to the managed care
entity or whoever the agency whoever is
on the other side of your hearing you
don't have to do anything fancy with the
page numbers you can just take a sharpie
and write 1 2 3 4 5 on the page numbers
and the cover sheet is just looks like
an index explaining what type of
document size on what pages but it will
make the hearing go quicker
if you can refer the hearing officer to
you know look at the approval from two
years ago on page 15 for example all
right what can I show or ghen eyes this
is a pretty apt title for these next few
slides you want to print out your
evidence packet in the case file I
recommend putting them in a three-ring
binder and so that you can you know have
yourself organized where you can't add
things you can you can get things to
things quickly you know some of these
these files may be you know if they're
ever sent to you electronically there's
it's just it's just too big of a file to
look at and to flip through the pages on
your computer so it's a lot better if
you're organized with a three-ring
binder as part of this organization we
recommend that you prepare one page
outline with everything that's happened
with with your child's case when you got
the denial notice when this these
reductions happen when you request the
internal appeal when that was you know
maybe denied you know when you got the
final denial of notice when you asked
for the Medicaid for your hearing so you
have all of that ready in case there's
any questions or issues that come up
during a fair hearing on those issues
also make sure that you have documented
all the individuals like the players
like we talked about earlier with the
medical directors any nurses that from
the managed care organization had a hand
in the denial decision and and note
whether they actually come to the fair
hearing you know that the medical
directors who will make the denial
assess and don't always come to the fair
hearing
now that's always the case for a
medically dependent children program
hearing or a BCP hearing those tmh be
medical directors have yet to show up
for a fair hearing they they send a
nurse to defend the denial decision that
the medical director made and so I
always point that out to the hearings
officer I mean the hearings officer
knows that but it pointed out and make a
point of it that the person who made
this analysis it didn't even come to the
fair hearing today to defend that denial
decision that's occasionally the case
also in a private duty nursing or
therapy case man's character will
sometimes just send a nurse or
we'll send a different medical director
for a private duty nursing case point
out that that medical director is not
the one who made the decision in your
child's case that the person did make
the decision isn't even here to take my
questions today those types of things
and so again organize organize organize
as far as preparing your witnesses
consider who you want to testify in your
fair hearing if it's a private duty
nursing hearing maybe you'll have one of
your trusted nurses for your child I
testified during the fair hearing about
your about your child I you know you
know figure out who you want to testify
and then have a time before the fair
hearing where you get with that person I
get with the people that you want to
participate with you in the fair hearing
and and have a hearing prep call you
know you guys can discuss the theme in
the theory of your case and the role
everybody's going to play on your side
of the fair hearing
you can roleplay and test out questions
whether you're what witnesses you know
those those questions that are designed
to kind of tell your story or have the
witnesses tell the story and get out the
information that that's important
regarding your child and the the need
for the service that's being denied or
reduced okay so in preparing for the
fair hearing as about I would say a week
or two weeks prior to fair hearing
that's when you need to make the
determination if you need more time so
as we stress you can ask for continuance
so at that time think have you received
all your documentation or your witness
is ready to go is there any issues with
maybe the date and time for some of your
witnesses and see if you need that
continuance and then make that
continuance at least as soon as possible
so about a week in a week and a half
prior to the fair hearing and make sure
that it has been processed again want to
stress not to just assume because you
sent in the request for continuance that
it has been granted
so also during that time you want to
make sure you've received the case file
and all the documentation you requested
and then again so proceeding to fair
hearing
once you decide who's going to testify
you might consider the order that you
want do you want to provide testimony
first maybe the nurses therapist is a
doctor going to need time to present
first and that could be a request that
you might make if there's going to be a
doctor present and they don't have the
time to wait until it's your opportunity
to provide their testimony you can ask
the hearing officer if the doctor is
allowed to proceed with their testimony
first again we would recommend that you
review all the documents prior to fair
sharing again one final time makes sure
that everything that you want to address
is tabbed so you can easily access it at
fair hearing and just know everything
possible about your evidence packets
their evidence packet and know the
reason for the smell so you can truly
make sure that that is expressed to the
fair hearing officer there also help if
you know the reason with the
cross-examination questions that you
should be preparing and also will help
just preparing you for your testimony in
terms of what you need to express and
get out we also suggest that you look
through the information that we'll
provide after this webinar maybe review
this look through all the information
the checklist see how prepared you are
prior to proceeding to fair hearing also
we would suggest you know after this
will provide the questions the answers
to your questions so look through that
see what other parents have asked and
make sure that if there's anything you
missed again that you'll have the
opportunity to maybe okay well if you're
looking at all the information I think I
need to request a letter from this this
doctor or this specialist
go ahead and ask for that additional
time and start making that request and
getting all the documentation that you
need
and just a quick tip for preparing for
your testimony we'd say it's better to
outline exactly what you want to get
across the major point I don't think
there's a such a thing as being too
prepared so it says it's not going to
hurt for you to drop down things maybe
type it out play with the fonts to see
this is a major point that I need to
make sure I get because as prepared as
you are it happens to all of us we can
prepare and there will be things we will
miss that's their hearing that we won't
mention that we'll remember afterwards
and that shouldn't be an issue
if you at least can ensure to yourself
you write down these are the major
points that I have to hit this is what I
really want the hearing officer to know
so just writing that out prior to fair
hearing will really help and just be
prepared to refute any reasons that they
give for the denial so again knowing the
their reasoning for denial will help
because during fair hearing
they might suggest a different reason
for the denial and that's something you
have to be aware of and prepared to
notify the fair hearing officer now that
wasn't included in their denial notice
we had no idea that that was the reason
for the denial and really stressed that
but they didn't give you that
opportunity to prepare because it wasn't
included in their denial notice and this
shouldn't be allowed to suggest a
different reason now at their hearing
this is Peter so I always remind parents
that and I know they'll be nervous
there are nervous even when where
they're representing their child you
have to remember that of everyone on the
phone call everyone in the hearing you
know more about your child than anyone
or all of those other people combined so
you shouldn't get too nervous because
you should be able to answer the
questions about your child's conditions
and your child's needs because you know
them best
the reason Hilary stressed knowing the
reasons given the denial is that's what
makes a fair hearing fair or more fair
if they give
see the nursing services were reduced
for because there are only four g-tubes
per day and the evidence shows and you
can establish that there's six a day and
you do that and then they say well it's
also because of and they come up with
another reason that wasn't included
you couldn't have prepared for that
other reason and so that would render
the hearing unfair and that's why you
pointed out to the hearing officer this
is what they said and their notice this
is what the documents say it isn't going
well for them and now they want to
change the reason so you have to be
aware of the reason and that's you know
the reason they give if you can discern
it that's what you need to focus on you
need to show that that isn't true the
notices aren't great however so it's
sometimes it's hard to tell the real
reason the other thing when you talk
about your child when they they go first
in the hearing and it's gonna be very
bland they're not gonna really make your
child sound like a person it's gonna be
very dry about procedural things and
when the request came in and when they
made a decision and sort of a cursory
summary of your child's conditions the
hearing officers are not lawyers and
they're not medical people so you need
to give a better picture of your child a
better picture of their conditions a
better picture of their needs a better
picture of all the assistance they
require or why they need the nursing or
why they're eligible for mdc-t
you have to paint a fuller picture for
these hearing officers they do a lot of
hearings every day so the more you can
explain in more detail about everything
your child's been through even if it
goes back further you know we'll talk
about prior surgeries prior things they
had to overcome things they had to go
through you know visits to the hospital
etc because you have to paint a picture
not only of your child's conditions and
needs but also the risks that going
without whatever services a tissue would
pose for them so be prepared outline
your quest outline your testimony so you
don't lose track and make sure you say
everything you want to say
right now you've gotten all your stuff
together you're putting together your
hearing pakis sent it to the hearings
officer now it's hearing day you know
and here's some basics you know the the
the hearing itself is designed to be
informal and they'll say that at the
beginning of the hearings officer will
say that at the beginning of their
hearing now there is some structure so
it doesn't completely get out of control
but it's supposed to be you know not not
formal supposed to be you know somewhat
I don't I wouldn't call it inviting but
it's not supposed to be too intimidating
I can feel intimidating though you know
remember these these hearings are almost
always conducted by phone you know you
use the the in front the toll-free
number and the hearing code to get into
your conference call again like Peter
stress the hearing officer is not a
lawyer or medical professional don't
assume they understand all of the
medical conditions and issues you know
you'll need to explain it to them as if
they've never heard this before the
Texas Rules of Evidence and procedure do
not apply so you don't have to worry
about any of those kinds of rules when
the hearings officer starts the hearing
they start with introductions they they
make sure everybody who's on the call me
is on the call they verify everybody's
name and role in the hearing and address
they they go through those procedural
you know issues about the hearing
process who's going to go first and and
you know when they're going to you know
come out with their hearing decision and
and all that they obviously they give a
statement that the that the hearing is
only based on the rules and processes
that the agency alleges supports their
action and that they're going to review
all the evidence and exhibits and into
term making their determination they
swear in all the witnesses during the
fair hearing and and and then like it
like Peter was saying earlier the agency
goes first always remember who your
audience is during the fair hearing you
may be tempted to try to convince the
agency if that made a denial decision or
the
medical director at the you know at the
be hearing and say a private duty
nursing hearing that they are wrong and
you're trying to get them to admit
they're wrong well that's that's that's
probably going to be pretty futile
because it's unlikely that the medical
director is is gonna you know say in the
middle of the fair hearing you know what
you're right I was completely wrong
that's not likely to happen so your your
target is going to be the hearing
officer again they're not a lawyer or a
person with medical background you know
you know you you you might think that
they're not going to understand
everything and all the issues with your
child but you know this is where you
come in with your planning and all the
evidence that you've put together and
and like Peter was saying you know that
agency is not going to really you know
well on their side of the hearing
they're gonna they're not going to
really talk about your child like it
like a person they're going to talk
about him like a number or a client but
you're going to paint a better more
fuller picture for the hearings officer
so they can completely understand your
child and their needs and why they need
the services that have been denied
you're going to go over the the letters
of medical necessity that you that you
have presented and you're going to put
on the record what the doctors your own
doctors have said about your child's
needs and consider for your evidence
back in writing your own letter about
your child and why they need the
services that have been either reduced
or denied during the fair hearing make
sure that you pay close attention to the
people that have come to participate in
that in the fair hearing especially for
the agency you know write down all the
people on you know on a piece of paper
you know know who actually had any kind
of role in the decision if they didn't
have a role in the decision then you're
going to make sure that that's brought
up in the fair hearing if a medical
director who comes to the fair hearing
didn't actually have any kind of say or
or didn't even make the
decision then then you could have that
question did you know did you even
review the information did you make that
analysis in my child's case then make a
point that the person who did make the
denial decision is not even there today
to defend or take questions from you
about their their denial process you
know that you can do that during your
during your cross-examination and the
evidence before all that the evidence
was going to be admitted into the record
the agency will admit the evidence that
they're going to present during the
figuring it's usually the packet that
you receive and pay close attention as
they read it into the record so you can
figure out whether they are mentioning
something that you didn't receive if
that is the case always make sure that
you notify the hearings officer
immediately and say look I didn't get
that I didn't get that evidence that
there that they said that they sent me
and that could be grounds for the
hearing to be at least postponed to
reconvene for a later date while that
managed care organization sends you the
information they were supposed to have
sent me before the hearing
okay now
as I mentioned Tech Medicaid will
present its case first write down the
information that they provide especially
if it's if it's contrary to what you
have provided and then you can point
those issues out when it's when you per
you can when it's your opportunity to
ask questions after you know the agency
goes say the managed care organization
puts on their case before you even do
your side of the case again you can ask
questions of them based on their
testimony and that's called the
cross-examination remember Texas
Medicaid whether it's tmh fee or or
whether it's the managed care
organization they have the burden of
proof they have to show by a
preponderance of evidence which is more
likely true than not that they that
their reduction or denial was based on
policy and procedure and correct
remember we we mentioned this earlier
but always listen for new reasons for
denial because they're not allowed to do
that if that reason that they tried to
bring up it's not in the original denial
letter then there's no way you could
have ever been prepared for that and and
submit evidence to to rebut that reason
that they just come up with in in the
middle of the fair hearing bring that up
to the hearings officer and not allow
the managed care organization RTM HP to
to provide testimony on a new denial
reason again after they're done with
their side of the case you can you can
ask them questions and that's your
opportunity to ask those
cross-examination cross-examination
questions of the of the representative
this is Peter and I know we're running
short on time but I did want to mention
something about cross-examination you
know it's difficult it's not like it is
on TV where you're going to say
something and they're gonna blurt out
they were wrong and your child is
eligible or they made a mistake on the
nursing and you don't have to
cross-examine you can put on your case
and give your reasons why their decision
was incorrect and your reasons why your
child is eligible for mbcp or your child
needs those nursing hours but if you do
want to ask them questions and what
makes it difficult in these hearings is
you don't really know
is gonna show up and you really don't
know what they're gonna say so knowing
all of the evidence you know your child
so knowing all of the evidence so if
they do say something that's incorrect
you can point that out you know you can
point out that you know you could say
something like isn't it true that my
child's been getting private duty
nursing at this number of hours for the
past year and a half that's correct
right so you can get you could get a few
things cleared up and cross-examination
what you don't want to do is give them
open-ended questions where they're going
to just keep reiterating their reason
for denying or reducing it be better to
focus on since you're not lawyers it
would be better to focus on your side of
the case but if you have certain
questions or you can point out you know
in the in the sks AI that list of
diagnoses that left out three of my
child's diagnosis right like you can do
it that way and point out some errors or
say the criteria is this isn't that
right so you can clear up some things
but I don't think you have to do a lot
on cross-examination because I don't
think it's easy for parents I think it's
better to go ahead and explain to the
hearing officer why your child is
eligible or why they need that amount of
therapy or why they need that much of
Nursing so think about that I know we've
only got 10 minutes left so let me go to
the next slide yeah after you've asked
if you determined you want to ask
cross-examination questions after all of
that you have the opportunity to put on
your child's case and testify again like
Peter said about your child
you know them best you know so you talk
about their current conditions their
need for the service that's been
requested
I mean denied or reduced the history of
your child and Medicaid what has been
approved in the past you know in an mbcp
hearing my child was approved for five
years in a row and they started out old
all these conditions you know five years
ago and they still have all the same
conditions and issues you know when
you're when you're doing your side
education you're pointing out different
parts of your hearing submission and
exhibits make sure you refer to the
patient
so that makes it easy for the hearings
officer to find what you're looking for
when they're following a law now after
you testify you know the Texas Medicaid
you know as you have the opportunity to
ask them questions after their
presentation they have that same
opportunity and Texas Medicaid and the
hearings officer can ask you questions
and so just people I be honest committed
to your theory and and side of the case
remember who your audience is you're not
trying to convince Texas Medicaid that
they may you know that they are wrong
and that they should reverse your
audience at the hearings officer and
always answer the question that's asked
don't give in
don't answer some other you know or give
some other answer to another question
just answer whatever they ask and if you
don't know there's no harm in saying
that you just don't know
did you know don't try to answer a
question that you don't know the answer
to yeah where we see that the most is if
the hearings not going well let's say in
an MD CP case and they can't explain why
they made the decision they might ask
the parent will tell you explain what
your child's nursing needs are and I
usually object and say this is the
parent of the child they don't know
nursing policy they're not nurses
they're not fluent in the nursing
occupation code that's your that's up to
you I know about my child I know about
their conditions I know about their
history on this program I don't I don't
know you know you can say you don't know
and if you don't know you don't know but
I wouldn't try to you know if you feel
they're asking you about policy or law
or rule or regulation that's really
outside of what you need to know and
just say you don't know that's not
something you know and then just add in
I don't know that but my doctors say
that my child is eligible my doctor says
these many nursing hours are needed
these have always been beneficial to my
child I can't tell you what's nursing
and what's not that's not my role and
Peter's you basically went over this
this next slide so we're going to go to
the slide that talks about considering
providing a closing statement
we recommend this and this is actually
my favorite part of doing a favor
you're able to you know give that
summation of your case and then why
Medicaid is wrong I mean it's your
opportunity to summarize the evidence
that you presented poke holes you know
summarizing the holes you may have poked
in in Medicaid's
case frame it the way you see it wrap it
up with a bow for the hearings officer
tell your story you know it in in
summary be cautious
you know what wanting to provide
additional information after Texas
Medicaid has given their closing
statement because you get to do a
closing statement first usually then
Texas Medicaid does theirs unless
something is clearly erroneous that they
said in their closing statement I would
I would you know resist the temptation
to it you have the last word so to speak
okay again at the end of the hearing you
can ask for the hearing to record to be
kept open if there's additional evidence
that you didn't have available but
you're waiting on and that you want to
submit for the hearings officers
consideration you can do that at the end
of the fair hearing as well now after
the hearing has been closed
if the hearing record is not going to be
kept open the hearings officer will
usually sometimes at the beginning of
the fair hearing let you know what their
deadline is for a hearings decision
they're going to tell you it's going to
be issued in writing and sent to your
address it can be anywhere from a few
weeks to a few months I mean typically
30 to 45 days but they may make a
decision before or after that deadline
they give themselves every hearings
officers a little bit different on
whether they keep their deadlines so be
aware of that continued services always
remember that's going to be provided
until the hearings officer actually
makes issues their denial decision so
keep on top of the managed care
organizations to send those additional
authorizations while the hearings
officer makes a decision if that if
that's an issue win or lose you can
always request the services again or or
during the
after you win the fair hearing the next
authorization request after that other
authorization period runs out you still
have to ask for the services again so
always remember that the fair hearing
doesn't affect you no subsequent
authorization requests for services and
every submission should always be as
up-to-date as possible so that you don't
have to go through a denial again
possibly post hearing remedies options
for if you lose a fair hearing okay if
it's a service you can always resubmit
you know have the provider agency if
it's nursing or physical therapy or or
or DME you can always try to re-request
the service with with additional or
better documentation on the cover letter
for the hearing decision that you get
from the hearings officer will have
information about if you're not happy
with their decision you can ask for an
administrative review of that decision
which is HHS C attorney reviewing all
the evidence and they in theory and the
hearing officers decision to make sure
that the hearings officer follow the
correct rules and made the correct
decision that's not always very
successful but it is something that that
that a person has the right to do if you
ask for administrative review and that
was that upholds the hearings officers
decision then you'll have 30 days after
that to request a judicial review which
is a court a district court in Texas in
Travis County is reviewing the hearings
officers decision a lot of times you
need a lawyer for that type of procedure
I think parents could probably try to do
that themselves but it may be very
difficult in addition there is a way to
to request a hearing be reopened after a
hearing decision within one year if
there was new evidence that wasn't
offered at the hearing that could have
affected the hearings officers outcome
or decision so that is something that
can be done that's that's not
an easy task as well but it is it is
something that that parents can do if
they so choose and we did have a couple
questions and we we probably have time
for one or two one was do you write the
hearing officer for continuances is that
the only person you contact for a
continuance and to get the case file and
the answer is yes once you're in hearing
once you get the fair hearing notice
from the hearing hearings officer then
all your requests I would suggest go
through the hearing officer so you tell
them you want the case file and for them
to ask the Texas Medicaid to get you the
case file in evidence packet it may come
from the evidence packet will probably
come from the hearing officer they
request that the managed care entity or
T MHP send you the case file so it made
you may receive it from them but you're
requesting the hearing officer to get it
for you so I I send all my requests to
the hearing officer because I let them
know hey I requested it you know two
weeks ago and the hearings next week and
I still don't have it so now I need more
time can you ask them again so that was
one question the other one can you
request the evidence packet by contact
the MCO the evidence packet is produced
by the managed care entity or T MHP and
provided to the hearings officer who
sends it to you so that's where you'll
get that from we have a lot of questions
I think we can probably answer them
today and get them out today at the
latest on Monday so we will get you
those there's a when the webinar ends
today there's a webpage that has all the
resources that will have the PowerPoint
you can also listen to this training
again it also gives our intake line
Terry and
and Hillary's email address I think is
on the first slide if you have any
specific questions that we don't answer
but I appreciate you listening in today
I know that was a lot of information
hopefully I think when you look at the
additional resources we've provided you
know sample letters of medical necessity
sample letters to the hearing officers
checklists for preparing for the fair
hearing I think I think that'll sort of
fill in some of the gaps that we
couldn't get to in an hour and a half
but I really appreciate everyone calling
in and thanks to Terry and Hillary who
prepare for hearings every day and a
really expert in it so I appreciate
everyone for calling in thank you Matt
do you have anything I do not think