SECTION 371.212. Utilization Review of Nursing Facilities

(a) OIG conducts utilization reviews of nursing facility providers for residents enrolled in fee-for-service and managed care.

(b) For purposes of this subchapter, Resource Utilization Group (RUG) means the 34-group case mix classification system selected by the state and established by CMS or a successor case mix classification system selected by the state.

(c) A nursing facility provider must conduct accurate, standardized, and reproducible assessments of each resident's functional capacity, using a minimum data set (MDS) assessment and the guidance of the Resident Assessment Instrument (RAI) User's Manual. These assessments must be conducted on the schedule required by HHSC. All MDS items coded on an MDS assessment must be in accordance with all applicable state and federal law, rules, and policy, including:

(1) the RAI User's Manual;

(2) CMS updates to the RAI User's Manual;

(3) 42 C.F.R. §483.20 (relating to Resident Assessment);

(4) administrative rules applicable to Medicaid providers, including 26 TAC Chapter 554 (relating to Nursing Facility Requirements for Licensure and Medicaid Certification); and

(5) HHSC and CMS policy guidance.

(d) A nursing facility provider must code on the MDS assessment only those events occurring during the look-back period. The look-back period is the assessment timeframe preceding the assessment reference date (ARD) that is used when coding each item on the MDS assessment. The ARD is the last day of the look-back period.

(e) Any information on the MDS assessment is part of each corresponding claim for Medicaid reimbursement.

(f) Electronic or digital signatures on an MDS assessment must comply with the RAI Manual and Texas Business and Commerce Code Chapter 322.

(g) A complete MDS assessment must include:

(1) a valid, supporting Long-Term Care Medicaid Information (LTCMI) form, or successor form required by HHSC, which the nursing facility provider must maintain with the corresponding MDS; and

(2) the signature and title of each person completing any section of the MDS assessment for Medicaid reimbursement and the sections and completion dates corresponding to each signature.

(h) Each individual signing the signature section of the MDS assessment is certifying that the information entered on the MDS assessment is accurate. Any individual or nursing facility provider that submits false or inaccurate information is subject to sanctions under Subchapter G of this chapter (relating to Administrative Actions and Sanctions).

(i) Upon request, a complete MDS assessment must be provided to the OIG nurse reviewer during the onsite or desk utilization review.

(j) When correcting errors in an MDS assessment prior to the start of an OIG utilization review, the nursing facility staff must use the MDS Correction Policy in the MDS RAI User's Manual. The nursing facility provider must maintain documentation in the clinical record that supports the corrected MDS assessment. Nursing facility staff must not correct or modify any MDS assessment reviewed during an OIG utilization review until after any reconsideration review and appeal has been finally determined.

Source Note: The provisions of this §371.212 adopted to be effective February 9, 2023, 48 TexReg 503