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Texas Administrative Code (Last Updated: March 27,2024) |
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TITLE 1. ADMINISTRATION |
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PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION |
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CHAPTER 371. MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY |
| SUBCHAPTER B. OFFICE OF INSPECTOR GENERAL |
| § 371.1. Definitions |
| § 371.3. Purpose and Authority |
| § 371.11. Scope |
| § 371.17. Detection |
| § 371.23. Surety Bond |
| § 371.25. Injunction to Prevent Disposing of Assets and Application to Debts |
| § 371.27. Prohibition against Solicitation of Medicaid or CHIP Recipients |
| § 371.29. Random Prepayment Review |
| § 371.31. Federal Felony Match |
| § 371.33. On-Site Reviews of Prospective Providers |
| § 371.35. Use of Statistical Sampling and Extrapolation |
| § 371.37. Audit of Managed Care Organizations |
| SUBCHAPTER C. UTILIZATION REVIEW |
| § 371.200. Inpatient Hospital Utilization Review Program |
| § 371.201. Case Selection Process |
| § 371.203. TMRP Review Process |
| § 371.204. Hospital Screening Criteria for TMRP, TEFRA, and Facility-Specific Per Diem Methodology Reviews |
| § 371.206. Denials and Recoupments for TMRP, TEFRA Hospitals, and Facility-Specific Per Diem Methodology Reviews |
| § 371.208. Appeals Related to Utilization Review Department Review Decisions |
| § 371.210. Inpatient Utilization Review for Hospitals Reimbursed Under TMRP and TEFRA Principles of Reimbursement and Facility-Specific Per Diem Methodology Reviews |
| § 371.212. Utilization Review of Nursing Facilities |
| § 371.214. HHSC-Approved Online RUG or Other HHSC-Required Training Course |
| § 371.216. Nursing Facility Clinical Records |
| § 371.218. Onsite and Desk Utilization Reviews of Nursing Facilities |
| § 371.220. Exit Conferences |
| § 371.222. Reconsideration of Utilization Review Results |
| § 371.224. Appeals of Reconsideration Results |
| § 371.226. Calculation of Overpayments and Underpayments |
| § 371.228. Recoveries |
| § 371.230. Waiver of Extrapolation |
| SUBCHAPTER E. PROVIDER DISCLOSURE AND SCREENING |
| § 371.1001. Applicability |
| § 371.1005. Disclosure Requirements |
| § 371.1007. Screening Levels |
| § 371.1009. Verifications Required for Each Screening Level |
| § 371.1011. Recommendation Criteria |
| § 371.1013. Provider Enrollment Recommendations |
| § 371.1015. Types of Provider Enrollment Recommendations |
| SUBCHAPTER F. INVESTIGATIONS |
| § 371.1301. Purpose |
| § 371.1305. Preliminary Investigation |
| § 371.1307. Full Investigation |
| § 371.1309. Training of Investigators |
| § 371.1311. Role of the OIG and SIUs |
| § 371.1312. Recipient Investigations |
| SUBCHAPTER G. ADMINISTRATIVE ACTIONS AND SANCTIONS |
| DIVISION 1. GENERAL PROVISIONS |
| § 371.1601. Applicability |
| § 371.1603. Legal Basis and Scope |
| § 371.1605. Provider Responsibility |
| § 371.1609. Notice and Service |
| § 371.1611. Due Process |
| § 371.1613. Informal Resolution Process |
| § 371.1615. Appeals |
| § 371.1617. Finality and Collections |
| § 371.1619. Award for Reporting Medicaid Fraud, Abuse, or Overcharges |
| DIVISION 2. GROUNDS FOR ENFORCEMENT |
| § 371.1651. Provider Eligibility |
| § 371.1653. Claims and Billing |
| § 371.1655. Program Compliance |
| § 371.1657. Unallowable Fiscal Gain |
| § 371.1659. Compliance with Health Care Standards |
| § 371.1661. Convictions and Prohibited Acts |
| § 371.1663. Managed Care |
| § 371.1665. Cost Report Violations |
| § 371.1667. Records and Documentation |
| § 371.1669. Self-Dealing |
| DIVISION 3. ADMINISTRATIVE ACTIONS AND SANCTIONS |
| § 371.1701. Administrative Actions |
| § 371.1703. Termination of Enrollment or Cancellation of Contract |
| § 371.1705. Mandatory Exclusion |
| § 371.1707. Permissive Exclusion |
| § 371.1709. Payment Hold |
| § 371.1711. Recoupment of Overpayments and Debts |
| § 371.1715. Damages and Penalties |
| § 371.1717. Reinstatement |
| § 371.1719. Recoupment of Overpayments Identified by Audit |