SECTION 352.9. Screening Levels

(a) HHSC assigns an applicant or re-enrolling provider a screening level of "Limited," "Moderate," or "High" based on:

(1) the federal screening level for the type of provider as provided by 42 CFR §424.518, if applicable;

(2) the federal screening level for the type of provider as provided by 42 CFR §455.450; or

(3) HHSC's assessment of:

(A) the risk level for potential fraud, waste, or abuse associated with the type of provider or the geographical area; or

(B) other factors as determined by HHSC, including:

(i) a change in business structure or organization;

(ii) past practices and circumstances; and

(iii) access to care in a geographical area.

(b) For a screening level of "Limited" or "Moderate" assigned under subsection (a) of this section, HHSC may assign a higher screening level based on provider, type of provider, or geographical area. For the requirements outlined in subsection (c) of this section, HHSC may rely on other validated screenings performed by Medicare, as provided for by 42 C.F.R. §455.410.

(c) Requirements for screening levels.

(1) Limited.

(A) For a provider assigned a screening level of "Limited," HHSC:

(i) verifies that a provider meets any federal or state requirements for that type of provider;

(ii) verifies licensure certifications, including licensure certifications in Texas and any other state; and

(iii) conducts database checks pursuant to 42 CFR §455.436.

(B) A provider assigned a screening level of "Limited" must submit a new enrollment application at least every five years, unless HHSC determines a shorter enrollment period.

(2) Moderate.

(A) For a provider assigned a screening level of "Moderate," HHSC:

(i) performs the screening described in paragraph (1)(A) of this subsection; and

(ii) performs at least one unscheduled and unannounced pre- and post-enrollment site visit in accordance with 42 CFR §455.432.

(B) A provider assigned a screening level of "Moderate" must submit a new enrollment application at least every five years, unless HHSC determines a shorter enrollment period.

(3) High.

(A) For a provider assigned a screening level of "High," HHSC:

(i) performs the screening described in paragraph (2)(A) of this subsection;

(ii) conducts a criminal background check; and

(iii) requires the submission of a set of fingerprints if applicable under 42 CFR §455.434.

(B) A provider assigned a screening level of "High" must submit a new enrollment application at least every three to five years, unless:

(i) HHSC determines a shorter enrollment period; or

(ii) the provider meets the requirements of §371.1007 of this title (relating to Screening Levels).

(d) In addition to the screening requirements provided under this section, additional screening may be performed under §371.1009 of this title (relating to Verifications Required for Each Screening Level).

(e) A screening level assigned under subsection (a)(3) of this section is within the sole discretion of HHSC and is not subject to administrative review.

Source Note: The provisions of this §352.9 adopted to be effective December 31, 2012, 37 TexReg 9899; amended to be effective May 2, 2016, 41 TexReg 3095