SECTION 371.1667. Records and Documentation

A person is subject to administrative actions or sanctions if the person:

(1) fails to make, maintain, retain, or produce adequate documentation according to Medicaid or other HHS policy, state or federal law, rule or regulation, or contract for a minimum period of:

(A) five years from the date of service or until all audit questions, administrative hearings, investigations, court cases, or appeals are resolved;

(B) six years or until all audit questions, administrative hearings, investigations, court cases, or appeals are resolved if the person is a Freestanding Rural Health Clinic; and

(C) ten years or until all audit questions, administrative hearings, investigations, court cases, or appeals are resolved if the person is a hospital-based Rural Health Clinic;

(2) fails to provide originals or complete and correct copies of records or documentation as requested upon reasonable request by a requesting agency; or

(3) fails to grant immediate access to the premises, records, documentation, or any items or equipment determined necessary by the OIG to complete its official functions related to a fraud, waste, or abuse investigation upon request by a requesting agency. Failure to grant immediate access may include, but is not limited to, the following:

(A) failure to allow the OIG or any requesting agency to conduct any duties that are necessary to the performance of their official functions;

(B) failure to provide to the OIG or a requesting agency, upon request and as requested, for the purpose of reviewing, examining, and securing custody of records, access to, disclosure of, and custody of copies or originals of any records, documents, or other requested items, as determined necessary by the OIG or a requesting agency to perform official functions;

(C) failure to produce or make available records within 24 hours of a request for production, for the purpose of reviewing, examining, and securing custody of records upon reasonable request, as determined by the OIG or a requesting agency except where the OIG or a requesting agency reasonably believes that requested documents are about to be altered or destroyed or that the request may be completed at the time of the request and/or in less than 24 hours;

(D) failure to grant access to a person's premises at the time of a reasonable request;

(E) failure to provide access to records at the time of a request, for the purpose of reviewing, examining, and securing custody of records upon reasonable request, when the OIG or a requesting agency has reason to believe that:

(i) requested documents are about to be altered or destroyed; or

(ii) in the opinion of the OIG or a requesting agency, the request could be met at the time of the request or in less than 24 hours;

(F) failure to relinquish custody of records and documents as directed by the OIG or a requesting agency;

(G) failure to complete a records affidavit, business records affidavit, evidence receipt, or patient record receipt, at the direction of the OIG or a requesting agency and to attach these documents to the records or documentation requested; or

(4) fails to make, maintain, retain, or produce documentation sufficient to demonstrate compliance with any federal or state law, rule, regulation, contract, Medicaid or other HHS policy, or professional standard in order to:

(A) participate in the Medicaid or other HHS program;

(B) support a claim for payment;

(C) verify delivery of services or items provided;

(D) establish medical necessity, medical appropriateness, or adherence to the professional standard of care related to services or items provided;

(E) determine appropriate payment for items or services delivered in accordance with established rates;

(F) confirm the eligibility of a person to participate in the Medicaid or other HHS program;

(G) demonstrate solvency of risk-bearing providers;

(H) support a cost or expenditure;

(I) verify the purchase and actual cost of products, items, or services; or

(J) establish compliance with applicable state and federal regulatory requirements.

Source Note: The provisions of this §371.1667 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