reglab/statecodes huggingface dataset:
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 B - OFFICE OF INSPECTOR GENERAL › Section 371.37 - Audit of Managed Care Organizations

Current through Reg. 49, No. 28; July 12, 2024
(a) The Office of Inspector General (OIG)
				  plans and conducts regular audits of Managed Care Organizations (MCOs)
				  participating in Medicaid . OIG audits of MCOs are conducted independent of the
				  Health and Human Services Commission (HHSC), but rely on the coordination
				  described in this section.
(b) For
				  purposes of this rule, "MCO" includes any entity with which an MCO
				  contracts.
(c) OIG's roles and
				  responsibilities for audits of MCOs include:
(1) coordinating with the HHSC Medicaid and
				  CHIP Services Division (MCSD) and Health and Human Services (HHS) Internal
				  Audit Division in the development of audit plans to minimize duplication of
				  activities relating to audits of MCOs;
(2) conferring with MCSD on potential OIG MCO
				  audits;
(3) considering input from
				  MCSD, including input into the development of risk assessment methodologies;
(4) considering audit requests by
				  HHS System executive management;
(5) performing risk assessments to select
				  MCOs or MCO activities for audit;
(6) considering previous audit and review
				  findings of MCOs by MCSD, HHS Internal Audit Division, and HHSC audit
				  contractors;
(7) submitting to the
				  HHS Executive Commissioner, at least annually, a draft audit plan identifying
				  the OIG's planned audits of MCOs;
(8) considering and responding to any
				  comments, or alternative or additional audit topics, submitted to the OIG by
				  the HHS Executive Commissioner, or the HHS Executive Commissioner's designee,
				  on the OIG's draft audit plan before finalizing the annual audit plan;
(9) consulting with MCSD
				  management, consulting with subject matter experts, and, when necessary,
				  obtaining specialized training, to ensure the OIG has sufficient knowledge and
				  understanding of managed care-related policies and contract requirements to
				  effectively conduct audits of MCOs;
(10) communicating preliminary results of MCO
				  audits to MCSD for review and comment;
(11) considering MCSD comments before
				  finalizing MCO audit report recommendations; and
(12) sharing proposed audit findings with
				  MCSD before issuing a final report to an MCO or to MCSD.
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 371.200 - Inpatient Hospital Utilization Review Program

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC conducts the TMRP in accordance
				  with:
(1) applicable federal regulations at 42
				  C.F.R. Part 456, Subparts A, B, and C, which require HHSC to operate a
				  utilization review program that controls the utilization of inpatient hospital
				  services and assesses the appropriateness and quality of those services;
				  and
(2) an approved waiver under
				  the Social Security Act, §1903(i)(4), as it relates to the use of Title
				  XVIII utilization review procedures for Title XIX patients in acute care
				  general hospitals other than hospitals reimbursed under TEFRA reimbursement
				  principles.
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 371.201 - Case Selection Process

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC selects
				  TMRP cases for review by a statistically valid random sampling methodology
				  and/or focused case selection. Cases consist of paid inpatient claims for
				  diagnosis-related groups (DRGs), which may include:
(1) readmissions up to 30 days;
(2) ambulatory surgical procedures billed on
				  inpatient claims;
(3) questionable
				  admissions or claims coding identified by other entities;
(4) admissions identified through HHSC's
				  quality review program as potential quality of care concerns;
(5) DRG payments made to freestanding
				  rehabilitation facilities;
(6) day
				  or cost outlier payments; or
(7)
				  any other DRG or claims submission errors.
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 371.204 - Hospital Screening Criteria for TMRP, TEFRA, and Facility-Specific Per Diem Methodology Reviews

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC uses
				  recognized evidence-based guidelines for inpatient hospital screening criteria.
				  Non-physician reviewers use the guidelines as criteria for the initial approval
				  or for the referral of inpatient reviews for medical necessity decisions. If
				  the criteria are not met or if the non-physician reviewer has any questions
				  concerning the appropriateness of coding or quality of care, the non-physician
				  reviewer refers the medical record to a physician consultant under contract
				  with HHSC for a decision. Even if the criteria are met, the physician
				  consultant may determine that an inpatient admission was not medically
				  necessary, and HHSC issues an admission denial. 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. A physician consultant may determine that an inpatient
				  admission was not medically necessary if a physician admitted a patient in
				  observation status and the patient was discharged from the outpatient status
				  within the Texas Medicaid Provider Procedures Manual, or any subsequent
				  provider manuals, defined observation period.
(b) For the purposes of the TMRP, TEFRA, and
				  facility-specific per diem methodology reviews, medical necessity means that
				  the patient has a condition requiring treatment that can be safely provided
				  only in the inpatient setting.
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 371.208 - Appeals Related to Utilization Review Department Review Decisions

Current through Reg. 49, No. 28; July 12, 2024
If a hospital receives notification from HHSC Utilization
					 Review Unit of an adverse decision regarding medical necessity of admission,
					 days of stay, diagnosis related group (DRG) validation, or a final technical
					 denial, the hospital may appeal to HHSC. The written notification of adverse
					 decision sets out the responsible area and time frame within which HHSC must
					 receive the appeal. The Texas Medicaid Policy and Procedure Manual provides
					 additional information on the appeal process.
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 371.210 - Inpatient Utilization Review for Hospitals Reimbursed Under TMRP and TEFRA Principles of Reimbursement and Facility-Specific Per Diem Methodology Reviews

Current through Reg. 49, No. 28; July 12, 2024
(a) The TEFRA and
				  facility-specific per diem methodology reviews process includes the following:
(1) Admission review to evaluate the medical
				  necessity of the admission. For purposes of the TMRP, TEFRA, and
				  facility-specific reviews, medical necessity means the patient has a condition
				  requiring treatment that can be safely provided only in the inpatient
				  setting.
(2) Continued stay review
				  to verify the medical necessity of each day of stay.
(3) Quality of care review to assess whether
				  the quality of care provided meets generally accepted standards of medical and
				  hospital care practices or puts the patient at risk of unnecessary injury or
				  death. Quality of care review includes the use of discharge screens and generic
				  quality screens. If quality of care issues are identified, physician
				  consultants under contract with HHSC and of the specialty related to the care
				  provided determine possible clinical recommendations or corrective
				  actions.
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 371.212 - Utilization Review of Nursing Facilities

Current through Reg. 49, No. 28; July 12, 2024
(a) OIG conducts
				  utilization reviews of nursing facility providers for residents enrolled in
				  fee-for-service and managed care.
(b) For purposes of this subchapter, Resource
				  Utilization Group (RUG) means the 34-group case mix classification system
				  selected by the state and established by CMS or a successor case mix
				  classification system selected by the state.
(c) A nursing facility provider must conduct
				  accurate, standardized, and reproducible assessments of each resident's
				  functional capacity, using a minimum data set (MDS) assessment and the guidance
				  of the Resident Assessment Instrument (RAI) User's Manual. These assessments
				  must be conducted on the schedule required by HHSC. All MDS items coded on an
				  MDS assessment must be in accordance with all applicable state and federal law,
				  rules, and policy, including:
(1) the RAI
				  User's Manual;
(2) CMS updates to
				  the RAI User's Manual;
(3)
											42 C.F.R. §
												483.20 (relating to Resident
				  Assessment);
(4) administrative
				  rules applicable to Medicaid providers, including 26 TAC Chapter 554 (relating
				  to Nursing Facility Requirements for Licensure and Medicaid Certification);
				  and
(5) HHSC and CMS policy
				  guidance.
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 371.214 - HHSC-Approved Online RUG or Other HHSC-Required Training Course

Current through Reg. 49, No. 28; July 12, 2024
All nursing facility registered nurse (RN) assessment
					 coordinators must successfully complete the HHSC-approved online RUG, or an
					 HHSC-approved successor training, within the HHSC-required time period. An RN
					 assessment coordinator who signs the Long-Term Care Medicaid Information
					 (LTCMI) or successor form or certifies the completeness of a minimum data set
					 (MDS) assessment for Medicaid reimbursement must, at the time of signing, be
					 current on his or her HHSC-approved RUG, or other HHSC-required,
					 training.
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 371.216 - Nursing Facility Clinical Records

Current through Reg. 49, No. 28; July 12, 2024
(a) All coded items
				  on minimum data set (MDS) assessments must be accurate and supported by
				  documentation in the recipient's clinical record. Completion of the MDS
				  assessment does not remove the nursing facility provider's responsibility to
				  document in the clinical record a detailed assessment of all relevant issues
				  that affect the recipient.
(1) Clinical
				  documentation must contain individualized care plans and document pertinent
				  facts, findings, and observations about an individual's health history,
				  including past and present illnesses, treatments, and outcomes to support the
				  assessment and the care provided.
(2) Sources of information, such as other
				  health care professionals and family members, utilized for the MDS assessment
				  must be identified in the clinical record.
(3) Clinical records must include the
				  recipient's name and the signatures, dates of signatures, and titles of
				  individuals providing care for the recipient.
(4) Documents, such as grids and flow sheets
				  that include entries by multiple staff members at different times, must include
				  complete dates with initials or signatures to clearly identify who provided the
				  care. For purposes of this paragraph, a signature may be an original
				  handwritten signature or an electronic signature as set out in Texas Business
				  and Commerce Code Chapter 322 (relating to the Uniform Electronic Transactions
				  Act).
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 371.218 - Onsite and Desk Utilization Reviews of Nursing Facilities

Current through Reg. 49, No. 28; July 12, 2024
(a) OIG selects
				  nursing facilities for utilization review by conducting a comprehensive annual
				  review of all facilities, considering factors such as:
(1) length of time since the last
				  review;
(2) whether the nursing
				  facility has ever been reviewed;
(3) previous review results;
(4) compliance history of the nursing
				  facility;
(5) nursing facilities
				  with claims in high-dollar reimbursement categories such as rehabilitation,
				  extensive services, and special care services;
(6) variances in billing patterns;
(7) data analytics indicating potential
				  fraud, waste, or abuse; and
(8)
				  complaints and referrals.
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 371.220 - Exit Conferences

Current through Reg. 49, No. 28; July 12, 2024
(a) For onsite
				  reviews:
(1) OIG conducts an onsite, and
				  subsequent telephone, exit conference after the onsite review is
				  complete.
(2) The nurse reviewer
				  communicates preliminary findings to the nursing facility staff during the
				  onsite exit conference.
(3) OIG
				  conducts a telephone exit conference after the onsite exit
				  conference.
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 371.222 - Reconsideration of Utilization Review Results

Current through Reg. 49, No. 28; July 12, 2024
(a) The nursing
				  facility provider may submit a request to OIG for reconsideration of the
				  results of the onsite or desk utilization review.
(b) A complete reconsideration request must:
(1) be in writing;
(2) clearly identify the specific minimum
				  data set (MDS) assessment errors for which reconsideration is
				  requested;
(3) contain a detailed
				  description of the basis for each objection to the MDS assessment errors for
				  which reconsideration is requested;
(4) include any documents the nursing
				  facility provider believes are necessary to support each objection to the
				  identified MDS assessment errors for which reconsideration is requested,
				  including the documents the nursing facility provider provided during the
				  review;
(5) when requested, include
				  a signed and notarized OIG-approved records affidavit, for each record, that
				  properly authenticates the documents described in paragraph (4) of this
				  subsection as business records pursuant to Texas Rules of Evidence Rule 803(6)
				  and Rule 902(10);
(6) be sent to
				  the OIG Utilization Review unit at the electronic or physical address indicated
				  on the formal notification of RUG changes, or successor notification;
				  and
(7) be electronically submitted
				  or postmarked on or before the 15th calendar day after the telephone exit
				  conference; or, if the 15th calendar day falls on a Sunday or national holiday
				  as defined in Texas Government Code §
											662.003(a),
				  the following business day.
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 371.224 - Appeals of Reconsideration Results

Current through Reg. 49, No. 28; July 12, 2024
If a nursing facility provider disagrees with the results
					 of a reconsideration review, the provider may request a hearing to appeal a RUG
					 change pursuant to Chapter 357, Subchapter I of this title (relating to
					 Hearings Under the Administrative Procedure Act). A nursing facility provider
					 may not request a hearing to appeal a RUG change unless the provider made a
					 timely and complete request for a reconsideration review.
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 371.226 - Calculation of Overpayments and Underpayments

Current through Reg. 49, No. 28; July 12, 2024
(a) For each
				  specific RUG that is found to be in error during the review and for which no
				  timely and complete reconsideration review was requested, OIG may direct the
				  reclassification of the RUG and recover an overpayment, or reimburse an
				  underpayment, after the reconsideration request deadline has passed.
(b) For each specific RUG for which a
				  reconsideration review was granted and for which no hearing was requested, OIG
				  may direct the reclassification of the RUG and recover an overpayment after the
				  hearing request deadline has passed.
(c) For each specific RUG for which a timely
				  request for a hearing is made, OIG may direct the reclassification of the RUG
				  and recover an overpayment after a final decision regarding the appeal is
				  issued.
(d) OIG may recover
				  overpayments and reimburse underpayments after due process has been concluded
				  for all RUGs in the review.
(e) OIG
				  may use statistical sampling and extrapolation for nursing facility utilization
				  review cases in accordance with §
										371.35 of this title (relating to
				  Use of Statistical Sampling and Extrapolation).
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 371.228 - Recoveries

Current through Reg. 49, No. 28; July 12, 2024
(a) OIG recovers
				  any overpayments associated with a minimum data set (MDS) assessment error. OIG
				  may recover an overpayment if the overpayment was identified during an OIG
				  utilization review of a nursing facility provider. The provider is reimbursed
				  for any underpayments.
(b) An
				  overpayment amount is a debt owed to the Texas Medicaid program.
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 371.230 - Waiver of Extrapolation

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG may
				  waive the calculation of an overpayment by extrapolation for any of the RUG
				  classifications found in error.
(b)
				  A provider must request a waiver of extrapolation in writing on or before the
				  15th calendar day after receipt of the final notice of overpayment. The
				  provider's request for waiver of extrapolation must include sufficient evidence
				  to demonstrate good cause for the waiver. The OIG may request additional
				  evidence or documentation from the provider or other sources in evaluating the
				  request.
(c) The OIG is vested with
				  the sole discretion to evaluate the provider's showing of good cause and to
				  determine whether waiver of extrapolation is warranted.
(d) The decision to grant, deny, or modify a
				  request for waiver of extrapolation is not subject to administrative or
				  judicial review.
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 E - PROVIDER DISCLOSURE AND SCREENING › Section 371.1001 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter describes the disclosure
				  requirements for applications and screening criteria used by the OIG in making
				  a recommendation for an enrollment determination.
(b) This subchapter applies to:
(1) all applicants for enrollment as a
				  provider in the Medicaid program or CHIP; and
(2) if requested by an HHS agency, applicants
				  for enrollment with an HHS agency program.
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 E - PROVIDER DISCLOSURE AND SCREENING › Section 371.1005 - Disclosure Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) An
				  applicant must disclose in its enrollment application the identity of any
				  person or entity as requested by HHSC.
(b) The applicant's disclosures must identify
				  every person whose identity must be disclosed pursuant to the Affordable Care
				  Act, Title 42 of the Code of Federal Regulations, or state statute or
				  administrative rule, as amended. Such disclosures include owners, certain
				  subcontractors, creditors, managers, and agents.
(c) An applicant must disclose in its
				  enrollment application every person that previously had an ownership or control
				  interest in the applicant but whose interest was transferred to another person,
				  if the person's former interest was transferred to an immediate family member
				  or to a member of the person's household and the person's former interest was
				  transferred within one year before or at any time after receiving notice of any
				  potential adverse actions by a governmental entity against the person or
				  against a provider for which the person has or had an ownership or control
				  interest.
(d) An applicant must
				  disclose in the enrollment application all information required by state or
				  federal law or regulation, and all additional information requested by HHSC or
				  the OIG, in its discretion, during the provider screening and enrollment
				  process.
(e) If any information
				  required to be disclosed under this section changes during the processing of an
				  enrollment application, the applicant, provider, or person must disclose that
				  information pursuant to §
										RSA 352.21
				  of this title (relating to Duty to Report Changes).
(f) A failure by an applicant, provider, or
				  person to meet any of the disclosure requirements specified in this section
				  constitutes a material non-disclosure of relevant information.
(g) The OIG may use information submitted by
				  another HHS agency that relates to information required to be disclosed in lieu
				  of requiring another submission of the same information by the applicant,
				  provider, or person.
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 E - PROVIDER DISCLOSURE AND SCREENING › Section 371.1007 - Screening Levels

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG uses a
				  screening level of "Limited," "Moderate," or "High" risk, assigned in
				  accordance with §
										RSA 352.9 of
				  this title (relating to Screening Levels) to determine the verifications and
				  further screening required under §
										RSA
				  371.1009 of this subchapter (relating to
				  Verifications Required for Each Screening Level).
(b) Case-by-case recommendation of screening
				  levels. For any enrollment application, the OIG may, in its sole discretion and
				  on a case-by-case basis, recommend that HHSC assign a higher or lower screening
				  level in accordance with §
										RSA
				  352.9(b) of this
				  title if the OIG determines in its discretion that the applicant may pose an
				  increased risk of committing fraud, waste, or abuse or may demonstrate
				  unfitness to provide or bill for medical assistance items or services. The OIG
				  may make such a recommendation after considering all circumstances, including
				  the applicant's criminal, regulatory, and administrative sanction history, as
				  well as the following, if applicable:
(1) The
				  applicant or any person required to be disclosed in the enrollment application
				  is under a payment suspension based on a credible allegation of
				  fraud.
(2) The applicant or any
				  person required to be disclosed in the enrollment application has failed to
				  repay any overpayments incurred under Medicaid, CHIP, or other HHS
				  programs.
(3) The applicant or any
				  person required to be disclosed in the enrollment application was excluded from
				  participation in Medicaid, CHIP, or other HHS program during the ten years
				  before the date of the enrollment application.
(4) The applicant is seeking enrollment as a
				  provider type that was subject to a state or federal temporary moratorium, if
				  the moratorium was lifted within six months before the date of the enrollment
				  application.
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 E - PROVIDER DISCLOSURE AND SCREENING › Section 371.1009 - Verifications Required for Each Screening Level

Current through Reg. 49, No. 28; July 12, 2024
(a) For an applicant or provider assigned a
				  screening level of "Limited," the OIG verifies the accuracy and completeness of
				  the information in or related to the enrollment application and
				  RSA
				  455.450(a)(1),
				  information about the applicant contained in state or federal records,
				  including criminal history records, and any additional information requested of
				  the applicant by the OIG.
(b) For
				  an applicant assigned a screening level of "Moderate," the OIG:
(1) verifies all items described in
				  subsection (a) of this section; and
(2) reviews the results of a pre-enrollment
				  site visit in accordance with §
											RSA 352.9 of
				  this title (relating to Screening Levels), if applicable.
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 E - PROVIDER DISCLOSURE AND SCREENING › Section 371.1011 - Recommendation Criteria

Current through Reg. 49, No. 28; July 12, 2024
(a) A felony or
				  misdemeanor conviction, as defined in
				  RSA
				  1001.2, under Texas law, the laws of another
				  state, or federal law, may affect a provider's and/or person's ability to
				  participate.
(b) The OIG may
				  recommend denial of an enrollment application of the applicant or a person
				  required to be disclosed in accordance with §
										RSA
				  371.1005 of this subchapter (relating to
				  Disclosure Requirements) on the basis of information revealed through a
				  background check on the applicant, provider, or a person required to be
				  disclosed. A background check may include:
(1) information concerning the licensing
				  status of the health care professional;
(2) information contained in the criminal
				  history record information check performed in accordance with Texas Government
				  Code §
											RSA
				  531.1032;
(3) a review of federal databases;
(4) the pendency of an open investigation by
				  the OIG; and
(5) any other reason
				  that the OIG determines appropriate.
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 E - PROVIDER DISCLOSURE AND SCREENING › Section 371.1013 - Provider Enrollment Recommendations

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG makes a recommendation on each
				  enrollment application submitted for review in accordance with the requirements
				  of this subchapter (relating to Provider Disclosure and Screening) and Chapter
				  352 of this title (relating to Medicaid and Children's Health Insurance Program
				  Provider Enrollment), or other rule, as applicable. The recommendation is at
				  the sole discretion of the OIG, and is not subject to administrative review or
				  reconsideration.
(b) In making its
				  enrollment recommendation, the OIG may consider any relevant circumstance or
				  factor as it applies to the applicant, provider, or any person required to be
				  disclosed in the enrollment application in accordance with this subchapter and
				  Chapter 352 of this title, if applicable.
(c) Upon making a recommendation on a
				  complete application, the OIG informs HHSC of its recommendation. HHSC makes
				  the final enrollment decision after considering:
(1) the OIG's recommendation;
(2) any conditions for approval recommended
				  by the OIG;
(3) the availability of
				  access to care; and
(4) any other
				  relevant facts or circumstances.
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 E - PROVIDER DISCLOSURE AND SCREENING › Section 371.1015 - Types of Provider Enrollment Recommendations

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG may make the following types of
				  recommendations regarding an enrollment application:
(1) Approval. If an enrollment application is
				  recommended for approval, the recommendation is for a time-limited period of
				  participation as specified in the provider agreement or notification of the
				  enrollment decision. The prospective provider must complete and submit the
				  provider agreement before enrollment is granted.
(2) Conditional approval. An enrollment
				  application may be recommended for conditional approval with conditions as
				  specified in the notification of the enrollment recommendation. The conditions
				  may consist of the imposition of any one or more administrative actions or
				  sanctions as specified in Subchapter G of this chapter (relating to
				  Administrative Actions and Sanctions) or in other Medicaid or CHIP policy or
				  rule.
(3) Denial. If an enrollment
				  application is denied, HHSC sends a written notice of the decision by certified
				  mail to the address of record on the enrollment application. The reason or
				  reasons for denial are as specified in the written notice. If the denial is
				  based upon a pending investigation, charge, or other legal proceeding, the
				  applicant or provider is ineligible to reapply until such investigation or
				  proceeding is finally resolved.
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 F - INVESTIGATIONS › Section 371.1301 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter provides procedures for
				  the investigation of complaints or allegations to promote their just and
				  efficient disposition.
(b) This
				  subchapter governs the investigation of all jurisdictional complaints or
				  allegations before the OIG.
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 F - INVESTIGATIONS › Section 371.1305 - Preliminary Investigation

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG may
				  receive and investigate complaints related to fraud, waste, or abuse within
				  HHSC or an HHS agency. The OIG prioritizes complaints for purposes of
				  determining the order in which complaints are investigated, taking into account
				  the seriousness of the allegations made in a complaint. The OIG may consider
				  the following factors when opening cases and prioritizing cases for the
				  efficient management of the OIG's workload:
(1) the highest potential for recovery or
				  risk to the State;
(2) the history
				  of noncompliance with applicable law and regulations;
(3) identified fraud trends;
(4) internal affairs investigations according
				  to the seriousness of the threat to recipient or public safety or the risk to
				  program integrity in terms of the amount or scope of fraud, waste, or abuse
				  posed by the allegation that is the subject of the investigation;
(5) acts or the failure to act that
				  potentially threatens the public health or may result in physical harm to the
				  public; and
(6) the potential for
				  or actual physical destruction of state property, including the loss, theft and
				  destruction of State assets, property, benefits, or equipment.
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 F - INVESTIGATIONS › Section 371.1307 - Full Investigation

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG
				  begins a full investigation within 30 days of completing the preliminary
				  investigation if it determines that a full investigation is
				  warranted.
(b) The OIG may close a
				  full investigation for one or more of the following reasons, if the OIG
				  determines that:
(1) the investigative
				  research and evidence gathered during the full investigation indicates that
				  fraud, waste, or abuse is not present;
(2) there is no violation of Medicaid policy;
(3) there is no overpayment to
				  recover;
(4) the potential
				  identified overpayment is not cost-effective to pursue;
(5) the issues related to the complaint are
				  outside of OIG jurisdiction;
(6) a
				  referral to the appropriate licensure or oversight agency is deemed a more
				  appropriate action;
(7) the case
				  should be referred to another division of OIG for action;
(8) the provider should receive education;
(9) the Medicaid provider is
				  deceased or out of business; or
(10) no administrative action, sanction, or
				  overpayment is appropriate after weighing the following factors:
(A) the seriousness of the allegations and
				  potential program violations;
(B)
				  the investigative resources available to pursue the full investigation; and
(C) the sufficiency and strength
				  of evidence gathered in the full investigation.
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 F - INVESTIGATIONS › Section 371.1309 - Training of Investigators

Current through Reg. 49, No. 28; July 12, 2024
Investigators who investigate Medicaid providers for
					 potential fraud, waste, or abuse receive annual training on notice, service,
					 due process, and any additional regulations or policies that may affect the OIG
					 investigatory process.
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 F - INVESTIGATIONS › Section 371.1311 - Role of the OIG and SIUs

Current through Reg. 49, No. 28; July 12, 2024
(a) An
				  MCO is required by §
										RSA
				  353.502 of this title (relating to Managed
				  Care Organization's Plans and Responsibilities in Preventing and Reducing
				  Waste, Abuse, and Fraud) and §
										RSA 370.501 of this title
				  (relating to Purpose) to establish and maintain an SIU to investigate
				  allegations of waste, abuse, or fraud for all services in the MCO plan. If an
				  MCO suspects possible waste, abuse, or fraud, the MCO must conduct a
				  preliminary investigation in accordance with criteria in §
										RSA
				  353.502 and §
										RSA 370.501 of this
				  title. If the preliminary investigation confirms waste, abuse, or fraud , the
				  MCO must refer the matter to the OIG in accordance with §
										RSA 353.505 of
				  this title (relating to Recovery of Funds).
(b) For a potential overpayment amount less
				  than $100,000, the MCO pursues recovery of the overpayment, and remits one-half
				  of the recovered amount in accordance with §
										RSA 353.505 of
				  this title (relating to Recovery of Funds).
(c) For MCO referrals to the OIG where the
				  potential overpayment amount exceeds $100,000, the OIG accepts the referral and
				  conducts a preliminary investigation.
(1) The
				  OIG evaluates the allegation(s) and evidence from the MCO-SIU for intentional
				  deception, repeat billing pattern, or other indicators of questionable
				  practices.
(2) The OIG determines
				  within 30 business days whether to take additional investigative action, and
				  notifies the referring MCO of the decision.
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 F - INVESTIGATIONS › Section 371.1312 - Recipient Investigations

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG may
				  consider the following factors when opening and prioritizing recipient cases
				  for the efficient management of the OIG's workload:
(1) the highest potential for recovery;
(2) applicable federal timeliness
				  requirements;
(3) initial screening
				  information obtained to support the allegation raised in the
				  complaint;
(4) whether allegations
				  in the complaint are violations of applicable agency policy, law or
				  regulations; and
(5) any other
				  relevant information or analysis the OIG deems appropriate.
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 G - ADMINISTRATIVE ACTIONS AND SANCTIONS › Division 1 - GENERAL PROVISIONS › Section 371.1601 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) Unless otherwise provided, this
					 subchapter applies to all administrative actions and sanctions imposed by the
					 OIG and arising out of an investigation of fraud, waste, or abuse.
(b) This subchapter does not apply to system
					 recoupments or other administrative or clerical corrections.
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 G - ADMINISTRATIVE ACTIONS AND SANCTIONS › Division 1 - GENERAL PROVISIONS › Section 371.1603 - Legal Basis and Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG may
					 take administrative enforcement measures against a person or an affiliate of a
					 person based upon an investigation or finding, including an audit finding, in
					 the Medicaid or other HHS programs. Administrative enforcement measures may
					 include:
(1) making referrals for further
					 investigation or action;
(2) taking
					 an administrative action;
(3)
					 imposing a sanction;
(4) assessing
					 damages, penalties, costs related to an administrative appeal, and
					 investigative and administrative costs; or
(5) denying the enrollment of a person for
					 participation in the Medicaid program.
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 G - ADMINISTRATIVE ACTIONS AND SANCTIONS › Division 1 - GENERAL PROVISIONS › Section 371.1605 - Provider Responsibility

Current through Reg. 49, No. 28; July 12, 2024
(a) A Medicaid
					 or other HHS provider is responsible for:
(1)
					 the provider's own actions and omissions; and
(2) the actions and omissions of the
					 provider's affiliates, employees, contractors, vendors, and agents.
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 G - ADMINISTRATIVE ACTIONS AND SANCTIONS › Division 1 - GENERAL PROVISIONS › Section 371.1609 - Notice and Service

Current through Reg. 49, No. 28; July 12, 2024
(a) Service of
					 notice.
(1) When required by this subchapter,
					 the OIG provides written notice by:
(A) hand
					 delivery, in which case notice is presumed to be received on the date of
					 delivery;
(B) certified mail with
					 return receipt requested, in which case notice is presumed to be received on
					 the date of the signature of the addressee or its agent on the return receipt
					 or on the delivery date as reflected in the records of the United States Postal
					 Service if the return receipt is unsigned or certified mail is
					 unclaimed;
(C) registered mail, in
					 which case notice is presumed to be received on the date of delivery as
					 reflected in the records of the United States Postal Service;
(D) fax with confirmation page, in which case
					 notice is presumed to be received on the date of the confirmation of the fax;
					 or
(E) regular mail plus one of the
					 other methods enumerated in subparagraphs (A) - (D) of this
					 paragraph.
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 G - ADMINISTRATIVE ACTIONS AND SANCTIONS › Division 1 - GENERAL PROVISIONS › Section 371.1611 - Due Process

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG affords
					 to any provider or person against whom it imposes sanctions the administrative
					 due process remedies applicable to administrative sanctions as set forth in
					 this subchapter.
(b) The imposition
					 of administrative actions as defined in §
											RSA
					 371.1701 of this subchapter (relating to
					 Administrative Actions) does not give rise to due process remedies.
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 G - ADMINISTRATIVE ACTIONS AND SANCTIONS › Division 1 - GENERAL PROVISIONS › Section 371.1613 - Informal Resolution Process

Current through Reg. 49, No. 28; July 12, 2024
(a) A
					 person who is served a notice of intent to impose a sanction or notice of a
					 payment hold may request an informal resolution meeting (IRM) to discuss the
					 issues identified by the OIG in the notice.
(b) A written request for an IRM must:
(1) be sent by certified mail to the address
					 specified in the notice letter;
(2)
					 arrive at the address specified in the notice of intent to impose the sanction
					 no later than:
(A) for a payment hold, ten
					 days after service on the person of the notice of payment hold;
(B) for any sanction other than a payment
					 hold or notice of recoupment of overpayment or debt, 30 days after service on
					 the person of the notice; or
(C)
					 for a notice of recoupment or overpayment or debt, a person may request an IRM
					 any time prior to the issuance of the final notice;
(3) include a statement as to the specific
					 issues, findings, and/or legal authority in the notice letter with which the
					 person disagrees, and, in the case of a payment hold, why an IRM would be
					 beneficial for the resolution of the case;
(4) state the basis for the person's
					 contention that the specific issues or findings and conclusions of the OIG are
					 incorrect; and
(5) be signed by the
					 person or an attorney for the person. No other person or party may request an
					 IRM for or on behalf of the subject of the sanction.
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 G - ADMINISTRATIVE ACTIONS AND SANCTIONS › Division 1 - GENERAL PROVISIONS › Section 371.1615 - Appeals

Current through Reg. 49, No. 28; July 12, 2024
(a) A person who is served with final notice
					 of a sanction may appeal the imposition of the sanction.
(b) Request for hearing.
(1) A request for an administrative hearing
					 at HHSC Appeals Division or at SOAH on a final notice of overpayment, must be
					 received in writing by the OIG no later than 30 days after the date the person
					 is served the final notice.
(2) A
					 request for an administrative hearing at HHSC Appeals Division on a Final
					 Notice of Contract Cancellation, Final Notice of Exclusion, or Notice of Final
					 Assessment of Administrative Penalties must be received in writing by the OIG
					 no later than 15 days after the date the person is served the notice.
(3) A request for an expedited administrative
					 hearing at SOAH on a payment hold must be received in writing by the OIG no
					 later than ten days after the date the person is served the notice.
(4) A written request for an administrative
					 hearing must:
(A) be sent by certified mail to
					 the address specified in the notice letter;
(B) timely arrive at the address specified in
					 the final notice; and
(C) be signed
					 by the person or an attorney for the person. No other person or party may
					 request a hearing for or on behalf of the subject of the sanction.
(5) Other than a final notice of
					 overpayment or payment hold, an administrative hearing for a final notice of a
					 sanction is held at the HHSC Appeals Division.
(6) The costs for an administrative hearing
					 held at SOAH is borne by the OIG, but a provider is responsible for the
					 provider's own costs incurred in preparing for the hearing.
(7) All other costs incurred by either party,
					 including attorney's fees, transcript copies, expert fees, and deposition
					 costs, is the responsibility of the party incurring those costs.
(8) The OIG contacts the HHSC Appeals
					 Division or SOAH to request that the hearing be docketed. The OIG files a
					 docketing request for a payment hold hearing with SOAH not later than the third
					 day after the hearing is requested.