Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter C - UTILIZATION REVIEW › Section 371.206 - Denials and Recoupments for TMRP, TEFRA Hospitals, and Facility-Specific Per Diem Methodology Reviews

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Reviews conducted under the TMRP, TEFRA, and facility-specific per diem
				  methodology may result in denials of claims. HHSC notifies the hospital in
				  writing of the denial decision and instructs the claims administrator to recoup
				  payment. If a hospital claim is denied for lack of medical necessity or for
				  being provided in an inappropriate setting, HHSC considers for denial physician
				  and/or non-physician Medicaid provider claims associated with the hospital
				  admission or service when such claims can be identified and are deemed to be
				  the result of inappropriate admission orders. Physicians and/or non-physician
				  providers are notified in writing if the claim for professional services is
				  denied. The written notification of denial explains the appeal process. Types
				  of denials are:
(1) Admission and days of
				  stay denials. A physician consultant under contract with HHSC makes all
				  decisions regarding medical necessity, cause of readmission, and
				  appropriateness of setting.
(2)
				  Technical denials. HHSC issues a technical denial when a hospital fails to make
				  the complete medical record available for review within specified time frames.
				  These services may not be rebilled on an outpatient basis.
(A) For on-site reviews, if the complete
				  medical record is not made available during the on-site review, HHSC issues a
				  preliminary technical denial at that time. The hospital is allowed 60 calendar
				  days from the date of the exit conference to provide the complete medical
				  record to HHSC. If the complete medical record is not received by HHSC within
				  this time frame, HHSC issues a final technical denial. If HHSC requests a copy
				  of the medical record in writing, and the copy is not received within the
				  specified time frame, HHSC issues a preliminary technical denial by certified
				  mail or fax machine. The hospital has 60 calendar days from the date of the
				  notice to submit the complete medical record. If the complete medical record is
				  not received by HHSC within this time frame, HHSC issues a final technical
				  denial.
(B) For mail-in reviews,
				  HHSC requests copies of medical records in writing. If HHSC does not receive
				  the complete medical record within the specified time frame, HHSC issues a
				  preliminary technical denial by certified mail or fax machine. The hospital has
				  60 calendar days from the date of the notice to submit the complete medical
				  record. If HHSC does not receive the complete medical record within this
				  specified time frame, HHSC issues a final technical denial.
(3) Readmission denial. If it is
				  determined that the services provided in the second or subsequent admissions
				  were the direct result of a premature discharge or should have been provided in
				  the first or previous admission, HHSC denies the admission in
				  question.
(4) Day outlier denial.
				  If it is determined that any days qualifying as outlier days during the
				  admission were not medically necessary, HHSC denies those days.
(5) Cost outlier denial. If it is determined
				  that services delivered were not medically necessary, not ordered by a
				  physician and/or authorized non-physician, not rendered or billed
				  appropriately, or not substantiated in the medical record, HHSC denies those
				  services.