SECTION 353.1453. Due Process Procedures to Recoup an Overpayment Related to an EVV Visit Transaction that is not Fraud or Abuse and Limitation on Audit Period

(a) In an audit of a provider or FMSA conducted by a managed care organization (MCO), the MCO must limit the review of EVV visit transactions to those that occurred during the 24 months prior to the audit.

(b) If, based on an audit or investigation of a provider or FMSA, an MCO identifies a deficiency related to an EVV visit transaction that is not fraud or abuse and the MCO decides to recoup an overpayment because of the deficiency, the MCO must give the provider or FMSA written notice of the MCO's intent to recoup overpayments not later than the 30th day after the date the audit or investigation is completed.

(c) An MCO must include the following in the written notice required by subsection (b) of this section:

(1) a description of the basis for the intended recoupment;

(2) if the basis of the intended recoupment is an EVV visit transaction, the specific EVV visit transaction and associated claim that are the basis of the intended recoupment;

(3) if the basis of the intended recoupment is a missing EVV visit transaction, the claim for which there is no associated EVV visit transaction;

(4) that the MCO must receive a response to the notice from the provider or FMSA no later than the 30th day after the date the provider or FMSA receives the written notice, if the provider or FMSA intends to respond;

(5) the specific number of days allowed to correct and explain the deficiency before the MCO begins any efforts to collect overpayments, which must be no fewer than 60 days from the notice date;

(6) the process by which the provider or FMSA should communicate with and send information to the MCO about the EVV visit transactions that are the basis of the intended recoupment;

(7) the provider's or FMSA's option to seek an informal resolution with the MCO of the intended recoupment; and

(8) the MCO's process for the provider or FMSA to appeal the intended recoupment.

(d) A corrected deficiency is one that a provider or FMSA makes by doing one or both of the following:

(1) performing visit maintenance to correct an EVV visit transaction in accordance with HHSC EVV policy; or

(2) correcting and resubmitting a claim in accordance with MCO policies and procedures.

(e) An MCO may recoup an overpayment only if a provider or FMSA:

(1) does not correct the deficiency and does not appeal the alleged overpayment; or

(2) appeals the alleged overpayment and the final decision from the appeal is favorable to the MCO.

(f) If an MCO determines that a deficiency related to an EVV visit transaction is fraud or abuse, the MCO must comply with §353.1454 of this subchapter (relating to Due Process Procedures to Recoup an Overpayment Because of a Discovery of Fraud or Abuse).

Source Note: The provisions of this §353.1453 adopted to be effective February 7, 2022, 47 TexReg 496