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 2 - GROUNDS FOR ENFORCEMENT › Section 371.1653 - Claims and Billing

Current through Reg. 49, No. 28; July 12, 2024
A person is subject to administrative actions or
						sanctions if the person submits, or causes to be submitted, a claim for payment
						by the Medicaid or other HHS program:
(1) for an item or service for which the
					 person knew or should have known the claim or cost report was false or
					 fraudulent;
(2) for an item or
					 service that was not provided as claimed;
(3) for an item or service that requires
					 prior authorization, prior order, or prescription, where prior authorization,
					 prior order, or prescription was not properly obtained, including where prior
					 authorization, prior order, or prescription requirements were met by
					 misrepresentation or omission;
(4)
					 for an item or service that requires the name and National Provider Number of
					 the supervising, ordering, or referring person for prior authorization, where
					 the correct name and National Provider Number of the supervising, ordering, or
					 referring person were not provided;
(5) based on a code that would result in
					 greater payment than the code applicable to the item or service that was
					 actually provided;
(6) for an item
					 or service that was not coded, bundled, or billed in accordance with standards
					 required by statute, regulation, contract, Medicaid or other HHS program policy
					 or provider manual, and that, if used, has the potential of increasing any
					 individual or state provider payment rate or fee;
(7) for an item or service that was not
					 reimbursable by, permitted by, or associated with the Medicaid or other HHS
					 program, including an item or service substituted without authorization by the
					 Medicaid or other HHS program and a prescription drug substituted without
					 authorization by an HHS program;
(8) for any order or prescription in which a
					 false statement, misrepresentation, or omission of pertinent facts was made by
					 the ordering or prescribing person on a claim, attachments to a claim, medical
					 record, documentation used to adjudicate a claim for payment or to support
					 representations on cost reports, used by the provider to show the medical
					 necessity, or on documents used to establish fees, daily payment rates, or
					 vendor payments;
(9) for an item or
					 service where the charges for that item or service exceed the usual and
					 customary fee the person charges to the public, privately insured persons, or
					 private-pay persons for the same item or service, including a claim submitted
					 under Title XVIII (Medicare);
(10)
					 for an item or service where the charges or costs for that item or service were
					 discounted for the public, privately insured persons, or private-pay persons
					 for the same item or service, including a claim submitted under Title XVIII
					 (Medicare);
(11) for an item or
					 service that is furnished, prescribed, or otherwise ordered or presented by a
					 person that is excluded, terminated, or otherwise prohibited from participation
					 in an HHS program or any state or federally funded health care program, except
					 an order or prescription that was:
(A) written
					 before the exclusion or termination of a physician or other practitioner
					 legally authorized to write a prescription; and
(B) delivered within 30 days of the effective
					 date of such exclusion or termination;