SECTION 357.591. Notice of Adverse Action

(a) Except in the following circumstances, the department sends the provider prior written notification about its intent to impose an exclusion sanction and includes a time frame for the provider to take action necessary to correct the problem areas:

(1) any criminal conduct;

(2) any action by the federal government that would preclude federal financial participation (FFP);

(3) any conduct or omission of conduct that presents a significant health, safety, or security hazard to a recipient receiving services from the provider;

(4) any conduct or omission of conduct that causes financial loss to a recipient receiving services from the provider, if the financial loss is caused by a violation of the requirements of the Texas Medicaid Program;

(5) any conduct or omission of conduct by the provider that indicates a pattern of repeated violations of the Texas Medicaid Program;

(6) any conduct or omission of conduct by the provider that causes a significant loss of department funds paid for services not provided or not provided according to the requirements of the Texas Medical Assistance Program;

(7) any conduct or omission of conduct by the provider that would preclude the department or its authorized agents, representatives of the department of health and human services, or the attorney general's Medicaid Fraud Control Unit from obtaining, upon request, access to or copies of records of services provided to Medicaid recipients and payments made for those services including, but not limited to, documents related to diagnosis, treatment, service, lab results, and x-rays.

(b) When the department or its agent has notified a provider about a violation or an overpayment, future payments may be withheld on pending and subsequently received claims or all payments may be suspended pending a final determination. Recovery of overpayments may be calculated by applying a percentage, determined through sampling methods, the total claims paid for a particular service for a specified period of time.

(c) When the department decides to sanction a provider under §79.2112(a) of this title (relating to Administrative Sanctions and Actions), the provider is notified in writing. The notice includes a statement of the provider's right to request a formal review of the decision. Formal reviews are requested according to policies and procedures outlined in the department's legal services rules and procedures in the various program provider handbooks.

(d) Providers may request informal reviews of the department's or its agent's action regarding claims payment or administrative actions under §79.2112(c) of this title (relating to Administrative Sanctions and Actions).

(e) Letters notifying providers about exclusion must contain a description of the duration of the action and the method the provider uses to request reinstatement.

Source Note: The provisions of this §357.591 adopted to be effective February 29,1980, 5 TexReg 526; amended to be effective July 1, 1986, 11 TexReg 2825; amended to be effective December 15, 1988, 13 TexReg 5828; transferred effective September 1, 2004, as published in the Texas Register September 17, 2004, 29 TexReg 9013