SECTION 61.416. Verification

(a) The OAG may verify and investigate an application or award. Verification and investigation includes, but is not limited to:

(1) a verification of any evidence submitted to the OAG;

(2) a review of records submitted by a service provider; or

(3) a post payment audit to verify actual charges, bills, payments, and the delivery of goods or services.

(b) The OAG may require additional supporting documentation from a victim, claimant, or service provider.

(c) If the OAG determines that the supporting documentation is insufficient to process a payment, the OAG may deny payment.

(d) If the OAG determines that charges or bills submitted by a service provider are not in compliance with the laws and regulations governing a profession or industry, the OAG may notify the appropriate licensing or regulatory agency governing the service provider.

(e) A service provider is subject to a reduction or denial of payment, a request for a refund of any overpayments as described in §61.305 of this chapter (relating to Overpayments to Service Providers), and any other penalties authorized by law, for the following acts:

(1) submitting charges for services that were not rendered;

(2) submitting charges that are not reasonable and necessary;

(3) violating rules and regulation set forth by a state or federal licensing or regulatory agency; or

(4) failing to submit the required documentation for services rendered and payments received.

(f) In order to verify the reasonableness and necessity of certain pecuniary losses, a victim or claimant may be required to submit to an independent medical evaluation by an M.D. or a D.O. The evaluation will be scheduled and paid for by the OAG. In addition, a health care service provider who treats the victim or claimant may also be required to submit a current treatment recommendation.

(g) In order to receive or continue receiving compensation for personal injury that is or has been exacerbated by the criminally injurious conduct, a victim or claimant may be required to submit to an independent medical evaluation by an M.D. or D.O. The evaluation will be scheduled and paid for by the OAG. In addition, a health care service provider who treats the victim or claimant may also be required to submit medical documentation relating to the personal injury prior to and after the date of crime.

Source Note: The provisions of this §61.416 adopted to be effective October 30, 2014, 39 TexReg 8373