SECTION 371.1653. Claims and Billing

A person is subject to administrative actions or sanctions if the person submits, or causes to be submitted, a claim for payment by the Medicaid or other HHS program:

(1) for an item or service for which the person knew or should have known the claim or cost report was false or fraudulent;

(2) for an item or service that was not provided as claimed;

(3) for an item or service that requires prior authorization, prior order, or prescription, where prior authorization, prior order, or prescription was not properly obtained, including where prior authorization, prior order, or prescription requirements were met by misrepresentation or omission;

(4) for an item or service that requires the name and National Provider Number of the supervising, ordering, or referring person for prior authorization, where the correct name and National Provider Number of the supervising, ordering, or referring person were not provided;

(5) based on a code that would result in greater payment than the code applicable to the item or service that was actually provided;

(6) for an item or service that was not coded, bundled, or billed in accordance with standards required by statute, regulation, contract, Medicaid or other HHS program policy or provider manual, and that, if used, has the potential of increasing any individual or state provider payment rate or fee;

(7) for an item or service that was not reimbursable by, permitted by, or associated with the Medicaid or other HHS program, including an item or service substituted without authorization by the Medicaid or other HHS program and a prescription drug substituted without authorization by an HHS program;

(8) for any order or prescription in which a false statement, misrepresentation, or omission of pertinent facts was made by the ordering or prescribing person on a claim, attachments to a claim, medical record, documentation used to adjudicate a claim for payment or to support representations on cost reports, used by the provider to show the medical necessity, or on documents used to establish fees, daily payment rates, or vendor payments;

(9) for an item or service where the charges for that item or service exceed the usual and customary fee the person charges to the public, privately insured persons, or private-pay persons for the same item or service, including a claim submitted under Title XVIII (Medicare);

(10) for an item or service where the charges or costs for that item or service were discounted for the public, privately insured persons, or private-pay persons for the same item or service, including a claim submitted under Title XVIII (Medicare);

(11) for an item or service that is furnished, prescribed, or otherwise ordered or presented by a person that is excluded, terminated, or otherwise prohibited from participation in an HHS program or any state or federally funded health care program, except an order or prescription that was:

(A) written before the exclusion or termination of a physician or other practitioner legally authorized to write a prescription; and

(B) delivered within 30 days of the effective date of such exclusion or termination;

(12) for a home health service for which no in-person evaluation of the recipient was performed within the 12-month period preceding the date of the order or other authorization for the home health service;

(13) for durable medical equipment for which the physician, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife that ordered or otherwise authorized the durable medical equipment has failed to certify on the order or authorization that he or she conducted an in-person evaluation of the recipient within the 12-month period preceding the date of the order or other authorization;

(14) for an item or service for which the provider knowingly made, used, or caused the making or use of a false record or statement material to an obligation to pay or transmit money or property to this state under the Medicaid program, or knowingly concealed or knowingly and improperly avoided or decreased an obligation to pay or transmit money or property to this state under the Medicaid program;

(15) for an item or service that constitutes a violation of §32.039(b) or §36.002 of the Texas Human Resources Code;

(16) for an item or service rendered to a child who was not accompanied by an authorized adult or who was accompanied by the provider or its affiliate to treatment; or

(17) for damages, costs, or penalties collected or assessed by the OIG.

Source Note: The provisions of this §371.1653 adopted to be effective October 14, 2012, 37 TexReg 7989; amended to be effective April 15, 2014, 39 TexReg 2833; amended to be effective May 1, 2016, 41 TexReg 2941