(a) OO staff review all available information about a consumer through inquiry into HHS program systems before referring a contact to HHS staff for review.
(b) Each complaint is investigated to determine if HHS policy was followed by HHS staff and vendors contracted to provide services on behalf of an HHS program. Applicable policies include federal and state law, administrative rules, program handbooks, contracts, and internal program policies and procedures.
(c) OO staff consider the following when investigating a complaint:
  (1) Legal authority. What is the basis of the HHS program's decision, and was the decision made within the scope of that authority?
  (2) Procedural fairness and rights. Was the consumer given a full understanding of the situation, offered all applicable opportunities to appeal, and given sufficient time to respond when information was requested?
  (3) Agreed expectations. Did the HHS program follow through after agreeing to take particular actions, and did the program provide an adequate explanation of decisions?
(d) When OO staff research through available systems is not sufficient to address a concern or determine whether a complaint can be substantiated, OO staff request a response to the complaint from appropriate HHS staff.
(e) HHS staff are asked to respond to OO requests. If no response is received, a second communication is made, and documented in the HEART system. If still no response is received, the request is escalated to leadership within the HHSC program.
(f) Upon receipt of information from HHS staff, OO staff review to determine if the concern has been addressed and if OO staff can determine whether a complaint can be substantiated. If the response is found to be inadequate by OO staff or if additional information is required, OO staff refer the contact back to HHS staff for additional review.

Source Note: The provisions of this §87.115 adopted to be effective January 10, 2019, 44 TexReg 252