Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.6 - Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) General requirements for participation.
				The Children with Special Health Care Needs Services Act, Health and Safety
				Code, §
									35.004,
				requires that all providers be approved to participate in the program according
				to program criteria and procedures.
(1)
				Providers seeking approval for program participation must submit a completed
				application to the program or its designee including a signed provider
				agreement and all documents requested.
(2) All approved program providers must agree
				to abide by program rules and regulations and not to discriminate against
				clients based on source of payment.
(3) All program providers must agree to
				accept the program-allowed amount of payment (regardless of payer) as payment
				in full for services provided to program clients. Providers may collect
				allowable insurance or health maintenance organization co-payments in
				accordance with those plan provisions. Providers may not request or accept
				payment from the client or client's family for completing any program
				forms.
(4) The program is the payer
				of last resort, and program providers must agree to utilize all other public or
				private benefits available to the client including, but not limited to,
				Medicaid or Medicaid waiver programs, CHIP, or Medicare, and casualty or
				liability coverage prior to requesting payment from the program. Providers must
				agree to attempt to collect payment from the payer of other benefits. The
				program may pay for certain services for which other benefits may be available
				but have not been definitively determined. If other benefits become available
				after the program has paid for the services, the program shall recover its
				costs directly from the payer of other benefits or shall request the provider
				of services to collect payment and reimburse the program.
(5) Overpayments made on behalf of clients to
				program providers must be reimbursed to the program refund account by lump sum
				payment or, at the discretion of the department, in monthly installments or out
				of current claims due to be paid the provider. All providers must consent to
				on-site visits and audits by program staff or its designees.
(6) All approved providers must agree to the
				following:
(A) maintain and retain all
				necessary records and claims to fully document the services and supplies
				provided to a client for full disclosure to the program or its
				designee;
(B) retain these records
				and claims for a period of five years from the date of service, the client's
				21st birthday, or until all audit questions, appeal hearings, investigations,
				litigation, or court cases are resolved, whichever occurs last;
(C) provide unconditionally upon request,
				free copies of and access to all records pertaining to the services for which
				claims are submitted to the program or its designees; and
(D) allow the department, the Office of
				Inspector General, HHSC, or designees of these organizations access to its
				premises; and cooperate and assist with any audit or investigation.
(7) All program providers of
				services also covered by Medicaid must enroll and remain enrolled as Title XIX
				Medicaid providers. In order to be reimbursed by Medicaid as the primary payer,
				a provider must be enrolled on the date of service. The program will not
				reimburse an enrolled provider for any service covered under Medicaid that was
				provided to a program client eligible for Medicaid at the time of service. If a
				service covered by the program is not covered by Medicaid, the provider of that
				service is not required to enroll as a Medicaid provider. Any provider excluded
				by Medicaid for any reason shall be excluded by the program.
(8) Providers must comply with applicable
				Medicare standards.
(9) If a
				license or certification is required by law to practice in the State of Texas,
				the provider must maintain the required license or certification and practice
				within the scope of the license, certification, registration, and any other
				applicable requirements.
(10) All
				providers shall be responsible for the actions of their staff members who
				provide program services.
(11) Any
				provider may withdraw from program participation at any time by so notifying
				the program in writing.