Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 3 - PROVIDER REQUIREMENTS › Section 354.2322 - Provider Billing and Recovery from Other Liable Third Parties

Current through Reg. 49, No. 28; July 12, 2024
(a) Providers must make a good faith effort
					 to determine, at the time health care items or services are delivered or at any
					 time thereafter, whether the health care items or services being provided to
					 the recipient are a result of injuries caused by a person who is or may be
					 liable for payment for the health care items or services.
(b) Providers must submit information
					 relating to the existence or possible existence of third party liability
					 obtained from the recipient or legal representative of the recipient at the
					 time a claim is submitted to HHSC for payment, or at any time thereafter, or
					 when an informational claim is submitted under the provisions of §
											354.1003 of this chapter (relating
					 to Time Limits for Submitted Claims).
(c) Providers are required to pursue recovery
					 from third party resources whose liability has been established or is
					 undisputed, before submitting a claim for payment to HHSC unless otherwise
					 directed by HHSC.
(d) Providers who
					 identify a third party resource, within 12 months from the date of service, and
					 wish to submit a bill, or other written demand for payment or collection of
					 debt to a third party resource after a claim for payment has been submitted and
					 paid by HHSC, must: refund any amounts paid by Medicaid prior to submitting a
					 bill or other written demand for payment or collection of debt to the third
					 party resource for payment, and; comply with the provisions of subsection (e)
					 of this section. This section does not require a refund to Medicaid or prohibit
					 a provider from filing a statutory provider lien prior to submitting reasonable
					 requests for information to a third party resource or a representative of a
					 recipient to assess the likelihood of recovery from a third party
					 resource.
(e) Providers may retain
					 a payment from a third party resource in excess of the amount Medicaid would
					 otherwise have paid only if the following requirements are met:
(1) the provider submits an informational
					 claim to HHSC within the claim filing deadline contained in §
												354.1003 of this chapter indicating
					 the identity of the third party resource from whom recovery is being
					 pursued;
(2) the provider gives
					 notice to the recipient, or the attorney or representative of the recipient,
					 that the provider may not or will not submit a claim for payment to Medicaid
					 and the provider may or will pursue a third party resource, if one is
					 identified, for payment of the claim. The notice must contain a prominent
					 disclosure that the provider is prohibited from billing the recipient or a
					 representative of the recipient for any Medicaid-covered services, regardless
					 of whether there is an eventual recovery or lack of recovery from the third
					 party resource or Medicaid;
(3) the
					 provider establishes its right to payment separate of any amounts claimed and
					 established by the recipient; and
(4) the provider obtains a settlement or
					 award in its own name separate from a settlement obtained by or on behalf of
					 the recipient or award obtained by or on behalf of the recipient, or there is
					 an agreement between the recipient or attorney or representative of the
					 recipient and the provider, that specifies the amount which will be paid to the
					 provider after a settlement or award is obtained by the recipient.