Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter B - GENERAL PROVISIONS › Section 354.1450 - Audits of Medicaid Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) In
				  this section, "provider" means an individual, firm, partnership, corporation,
				  agency, association, institution, or other entity that is or was approved by
				  HHSC to provide Medicaid under contract or provider agreement with
				  HHSC.
(b) This section does not
				  apply to a computerized audit conducted using the Medicaid Fraud Detection
				  Audit System or an audit or investigation conducted by the Medicaid Fraud
				  Control Unit of the Office of the Attorney General, the Office of the State
				  Auditor, the Office of Inspector General, or the Office of Inspector General in
				  the United States Department of Health and Human Services.
(c) Except as described in subsection (b) of
				  this section, an agency auditing division or entity must:
(1) Notify the provider, and the provider's
				  corporate headquarters, if the provider is a pharmacy that is incorporated, of
				  the impending audit not later than the seventh day before the date the field
				  audit portion of the audit begins;
(2) Limit the period covered by an audit to
				  three years;
(3) Accommodate the
				  provider's schedule to the greatest extent possible when scheduling the field
				  audit portion of the audit;
(4)
				  Conduct an entrance interview before beginning the field audit portion of the
				  audit;
(5) Audit all providers of
				  the same type under the same standards and parameters;
(6) Conduct the audit in accordance with
				  generally accepted government auditing standards issued by the Comptroller
				  General of the United States or other appropriate standards;
(7) Conduct an exit interview at the close of
				  the field audit portion of the audit with the provider to review the agency's
				  initial findings;
(8) At the exit
				  interview, allow the provider to:
(A) Respond
				  to questions by the agency;
(B)
				  Comment, if the provider desires, on the initial findings of the agency;
				  and
(C) Submit additional
				  supporting documentation, for consideration, that meets the auditing standards
				  required by paragraph (6) of this subsection, to correct a questioned cost, if
				  there is no indication that the error or omission that resulted in the
				  questioned cost demonstrates intent to commit fraud;
(9) Provide to the provider a preliminary
				  audit report and a copy of any document used to support a proposed adjustment
				  to the provider's cost report;
(10)
				  Permit the provider to produce, for consideration, documentation to address any
				  exception found during an audit not later than the 10th day after the date the
				  field audit portion of the audit is completed;
(11) Deliver a draft audit report to the
				  provider not later than the 60th day after the date the field audit portion of
				  the audit is completed;
(12) Permit
				  the provider to submit, for consideration, a written management response to the
				  draft audit report or to informally appeal the findings in the draft audit
				  report not later than the 30th day after the date the draft audit report is
				  delivered to the provider. The informal appeal will consist of a desk review by
				  the auditing division or entity; and
(13) Deliver the final audit report to the
				  provider not later than the 180th day after the date the field audit portion of
				  the audit is completed or the date on which a final decision is issued on an
				  appeal made under subsection (d) of this section, whichever is later.