SECTION 42.160. Carrier Desk Audit of Bills

(a) During the audit, the carrier and the provider shall make reasonable attempts to resolve any questions or problems regarding the bill under audit. The provider shall submit to the carrier any additional information requested that is relevant to the audit. If a hospital bill is under review, the hospital shall submit the medical record at the carrier's request.

(b) Every audit shall be documented on the medical audit summary sheet, which shall include the following information:

(1) claimant's name;

(2) IAB claim number;

(3) provider's name, address, and federal tax identification number;

(4) health care provider-reviewer's report; and

(5) for each audited item, the following: applicable code; code description; amount billed; amount paid; and, if appropriate, amount reduced or denied, accompanied by a sufficient explanation for each reduction or denial.

Source Note: The provisions of this §42.160 adopted to be effective October 20, 1988, 13 TexReg 4994.