SECTION 419.376. IMD Provider Reimbursement and Termination

(a) Reimbursement for IMD services provided to eligible individuals begins on the date established by written notice from the department and is contingent upon validation of evidence of IMD provider eligibility as described in §419.375(c) of this title (relating to IMD Provider Eligibility for Reimbursement).

(b) An IMD provider's agreement with the department is subject to termination with written notice on the date that any of the following occurs:

(1) loss of Medicare and/or JCAHO certification;

(2) if applicable, loss of licensure as a psychiatric hospital;

(3) failure to meet requirements specified in 42 CFR §440.140(a) pertaining to providers of inpatient hospital services in institutions for mental diseases;

(4) demonstrated noncompliance with those provisions of the Texas Administrative Code, Title 25, Part I, that relate to patient care and treatment in inpatient mental health facilities, or with state laws governing admission and treatment of persons with mental illness;

(5) breach of the written provider agreement described in §419.375(a)(2) of this title (relating to IMD Provider Eligibility for Reimbursement);

(6) termination of participation as a Medicaid provider by HHSC; or

(7) evidence of noncompliance with the rules in this subchapter or a corrective action plan that is based on findings made by the department in a review described in §419.375(c) of this title.

(c) Failure to submit an acceptable cost report in the required time frame constitutes a contract violation and may result in sanctions provided for in the contract, including a hold of vendor payments.

(d) Termination of the IMD provider agreement is an adverse action for which the IMD provider is entitled to a contested case hearing as described in Texas Administrative Code, Title 1, Chapter 357, Subchapter I (relating to Formal Appeals).

(e) IMD providers that receive Medicaid reimbursement for IMD services are governed by Texas Administrative Code, Title 1, Chapter 371 (relating to Medicaid and other Health and Human Services Fraud and Abuse Program Integrity.

Source Note: The provisions of this §419.376 adopted to be effective December 20, 1998, 23 TexReg 12683; amended to be effective July 3, 2007, 32 TexReg 4010