SECTION 371.222. Reconsideration of Utilization Review Results

(a) The nursing facility provider may submit a request to OIG for reconsideration of the results of the onsite or desk utilization review.

(b) A complete reconsideration request must:

(1) be in writing;

(2) clearly identify the specific minimum data set (MDS) assessment errors for which reconsideration is requested;

(3) contain a detailed description of the basis for each objection to the MDS assessment errors for which reconsideration is requested;

(4) include any documents the nursing facility provider believes are necessary to support each objection to the identified MDS assessment errors for which reconsideration is requested, including the documents the nursing facility provider provided during the review;

(5) when requested, include a signed and notarized OIG-approved records affidavit, for each record, that properly authenticates the documents described in paragraph (4) of this subsection as business records pursuant to Texas Rules of Evidence Rule 803(6) and Rule 902(10);

(6) be sent to the OIG Utilization Review unit at the electronic or physical address indicated on the formal notification of RUG changes, or successor notification; and

(7) be electronically submitted or postmarked on or before the 15th calendar day after the telephone exit conference; or, if the 15th calendar day falls on a Sunday or national holiday as defined in Texas Government Code §662.003(a), the following business day.

(c) Untimely or incomplete reconsideration requests are denied. MDS assessment errors not specifically identified in the reconsideration request are not reconsidered. MDS assessment errors that do not result in a RUG change are not reconsidered.

(d) If, as part of the reconsideration request, the nursing facility provider submits documents that were not provided to OIG prior to the telephone exit conference, these documents must be accompanied by:

(1) when requested, a signed and notarized OIG-approved records affidavit, for each record, that properly authenticates the documents as business records pursuant to Texas Rules of Evidence Rule 803(6) and Rule 902(10); and

(2) a signed and notarized affidavit, for each record, specifying why the record was not previously produced and the circumstances under which the documents were found, including the date found, the person who found the documents, and the location of the documents when found.

(e) At the conclusion of the reconsideration review, OIG Utilization Review issues written results of the review to the nursing facility provider.

Source Note: The provisions of this §371.222 adopted to be effective February 9, 2023, 48 TexReg 503