SECTION 354.1005. Unauthorized Charges

(a) An eligible provider must certify that no charges beyond reimbursement paid under the Texas Medicaid Program for a covered service or any function incidental to the provision of a covered service, have been, or will be, billed to an eligible recipient.

(b) Within the provisions cited in §354.1131 of this chapter (relating to Payments to Eligible Providers), an eligible provider may not bill or take other recourse against an eligible recipient for claims denied as a result of an error attributed to the provider.

(c) For purposes of subsection (a) of this section, functions incidental to the provision of a covered service include:

(1) signing, completing, or providing a copy of a health assessment form, such as a physical examination form required for the eligible recipient's enrollment in school or participation in school or other activities;

(2) providing a copy of a medical record requested:

(A) by or on behalf of any health care practitioner for purposes of medical care or treatment of the eligible recipient;

(B) under Texas Health and Safety Code §161.202;

(C) as a supplement to a form described in paragraph (1) of this subsection; or

(D) by an eligible recipient, for any reason, for the first time in a one-year period; and

(3) providing a copy of any subsequent amendment, supplement, or correction to a medical record under paragraph (2) of this subsection.

(d) An eligible provider may bill or otherwise charge an eligible recipient for providing a copy of a medical record not described in subsection (c)(2) of this section if the:

(1) eligible provider provided one copy of the medical record at no charge to the eligible recipient within one year before the request for an additional copy;

(2) medical record described in paragraph (1) of this subsection has not been amended, supplemented, changed, or corrected and contains the same documentation as the medical record requested under this subsection; and

(3) provider complies with state and federal law, including 22 TAC §165.2 (relating to Medical Record Release and Charges) and 45 C.F.R. §164.524.

(e) For purposes of this section, "medical record" includes a record with the elements described in 22 TAC §165.1(a) (relating to Medical Records). The term also includes a copy of a medical record created by another health care practitioner and in the possession of the eligible provider to whom a request for release of records has been made.

Source Note: The provisions of this §354.1005 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective October 26, 1984, 9 TexReg 5270; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective November 24, 2013, 38 TexReg 8187; amended to be effective March 8, 2015, 40 TexReg 917