SECTION 371.226. Calculation of Overpayments and Underpayments

(a) For each specific RUG that is found to be in error during the review and for which no timely and complete reconsideration review was requested, OIG may direct the reclassification of the RUG and recover an overpayment, or reimburse an underpayment, after the reconsideration request deadline has passed.

(b) For each specific RUG for which a reconsideration review was granted and for which no hearing was requested, OIG may direct the reclassification of the RUG and recover an overpayment after the hearing request deadline has passed.

(c) For each specific RUG for which a timely request for a hearing is made, OIG may direct the reclassification of the RUG and recover an overpayment after a final decision regarding the appeal is issued.

(d) OIG may recover overpayments and reimburse underpayments after due process has been concluded for all RUGs in the review.

(e) OIG may use statistical sampling and extrapolation for nursing facility utilization review cases in accordance with §371.35 of this title (relating to Use of Statistical Sampling and Extrapolation).

Source Note: The provisions of this §371.226 adopted to be effective February 9, 2023, 48 TexReg 503