Part I.
Texas Department of Human Services
Chapter 19.
Nursing Facility Requirements for Licensure and Medicaid Certification
Subchapter AA. Vendor Payment
40 TAC §19.2609
The Texas Department of Human Services (DHS) proposes new
§19.2609, concerning payment of claims, in its Nursing Facility Requirements
for Licensure and Medicaid Certification chapter. The purpose of the new section
is to implement a business rule for the claims management system (CMS) project.
Under the CMS project, DHS and the Texas Department of Mental Health and Mental
Retardation have partnered with the National Heritage Insurance Company (NHIC)
to develop an automated business system to consolidate claims submission and
processing for 19 different long term care programs of the two agencies. The
proposed rule states that claims should be submitted within 180 days of service.
Eric M. Bost, commissioner, has determined that for the first five-year
period the section is in effect there will be no fiscal implications for state
or local government as a result of enforcing or administering the section.
Mr. Bost also has determined that for each year of the first five years
the section is in effect the public benefit anticipated as a result of enforcing
the section will be that the proposed rule supports the implementation of
the Claims Management System, which will process claims accurately, on time,
within applicable program, accounting and Medicaid Management Information
System (MMIS) standards; be responsive to customers' needs; and be readily
adaptable to change. There will be no effect on small businesses because the
rule requires contractors to submit claims within 180 days of the last day
of service, but states that DHS has the option to pay claims received after
the 180-day time period. There is no economic effect for businesses, large
or small. The rule simply encourages contractors to submit claims in a timely
manner. There is no anticipated economic cost to persons who are required
to comply with the proposed section.
Questions about the content of this proposal may be directed to Susan Syler
at (512) 438-3111 in DHS's Long Term Care Policy Section. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-080,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas,
78714-9030, within 30 days of publication in the
Texas Register
.
The new section is proposed under the Human Resources Code, Title
2, Chapters 22 and 32, which authorizes the department to administer public
and medical assistance programs; and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The new section implements the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
§19.2609.Payment of Claims.
In order to receive payment for services provided, the nursing facility's
initial monthly claim for services must be received by the Texas Department
of Human Services' (DHS's) claim processor within 180 days after the end
of the service month.
(1)
All payments are subject to availability of funds as provided
by law.
(2)
Claims and adjustments received after the 180-day
time period may be paid upon approval by DHS. An excessive number of late
claims or adjustments may subject the service provider's claims procedures
to audit by DHS.
(3)
In the event that Medicaid eligibility for benefits
is established after provision of services, the 180-day period for submission
of claims will start on the date eligibility is established.
(4)
The procedures outlined in §19.2413 of this title
(relating to Reconsideration of Medical Necessity (MN) Determination and Effective
Dates) are not affected by this section.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
January 11, 1999.
TRD-9900106
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Proposed date of adoption: April 1, 1999
For further information, please call: (512) 438-3765
Subchapter D. Fiscal Monitoring
40 TAC §45.401, §45.403
The Texas Department of Human Services (DHS) proposes amendments
to §§45.401 and 45.403, concerning administrative errors and financial
errors, in its Community Living Assistance and Support Services (CLASS) chapter.
The purpose of the amendments is to delete the use of an unapproved substitute
form as an administrative error.
Eric M. Bost, commissioner, has determined that for the first five- year
period the proposed sections will be in effect there will be no fiscal implications
for state or local government as a result of enforcing or administering the
sections.
Mr. Bost also has determined that for each year of the first five years
the sections are in effect the public benefit anticipated as a result of enforcing
the sections will be to focus the administrative sanction on the collection
of the required data, rather than on the process of obtaining DHS approval
for a substitute form. If the provider fails to obtain DHS approval for the
substitute form, but collects all of the required data on the substitute form,
no administrative error will be cited. There will be no adverse economic effect
on small businesses because this change decreases the amount of fiscal sanctions
that may be imposed. There is no anticipated economic cost to persons who
are required to comply with the proposed sections.
Questions about the content of the proposal may be directed to Frances
Barraza at (512) 438-3216 in DHS's Community Care Section. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-070,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030,
within 30 days of publication in the
Texas Register
.
The amendments are proposed under the Human Resources Code, Title
2, Chapters 22 and 32, which provides the department with the authority to
administer public and medical assistance programs and under Texas Government
Code §531.021, which provides the Health and Human Services Commission
with the authority to administer federal medical assistance funds.
The amendments implement §§22.001-22.030 and 32.001-32.042 of
the Human Resources Code.
§45.401.Administrative Errors.
A recoupment of 12% of the paid unit rate is the administrative error
exception for services billed on an hourly basis. It represents the administrative
portion of the rate. Administrative errors are applied to the documentation
reviewed and are not extrapolated. Administrative errors include, but are
not limited to, the items in paragraph (1)-(2) of this section:
(1)
Administrative errors on documentation of services delivered
form [
(A)-(K)
(No change.)
[
(L)
[
(M)
[
(2)-(3)
(No change.)
§45.403.Financial Errors.
A reduction of 100% of the paid unit rate is the financial error exception.
This exception is applied to the unit(s) of service on the documentation reviewed
in the Community Living Assistance and Support Services (CLASS) program. This
exception is not extrapolated. Financial errors include, but are not limited
to, the following:
(1)
The Texas Department of Human Services (DHS) reimburses
the provider agency for services, but the CLASS documentation of services
delivered form, or [
(2)-(4)
(No change.)
(5)
DHS reimburses the provider agency for hours that
exceed the total number of hours recorded on the documentation of services
delivered form or [
(6)-(12)
(No change.)
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
January 8, 1999.
TRD-9900083
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Proposed date of adoption: May 1, 1999
For further information, please call: (512) 438-3765
Subchapter H. Administrative and Financial Errors
40 TAC §46.8002
The Texas Department of Human Services (DHS) proposes an
amendment to §46.8002, concerning list of administrative errors, in its
Licensed Personal Care Facilities Contracting with the Texas Department of
Human Services to Provide Residential Care Services chapter. The purpose of
the amendment is to delete the use of an unapproved substitute form as an
administrative error.
Eric M. Bost, commissioner, has determined that for the first five- year
period the proposed section will be in effect there will be no fiscal implications
for state or local government as a result of enforcing or administering the
section.
Mr. Bost also has determined that for each year of the first five years
the section is in effect the public benefit anticipated as a result of enforcing
the section will be to focus the administrative sanction on the collection
of the required data, rather than on the process of obtaining DHS approval.
There will be no adverse economic effect on small businesses because this
change decreases the amount of fiscal sanctions that may be imposed. There
is no anticipated economic cost to persons who are required to comply with
the proposed section.
Questions about the content of the proposal may be directed to Frances
Barraza at (512) 438-3216 in DHS's Community Care Section. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-070,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030,
within 30 days of publication in the
Texas Register
.
The amendment is proposed under the Human Resources Code, Title
2, Chapters 22 and 32, which provides the department with the authority to
administer public and medical assistance programs and under Texas Government
Code §531.021, which provides the Health and Human Services Commission
with the authority to administer federal medical assistance funds.
The amendment implements §§22.001-22.030 and 32.001-32.042 of
the Human Resources Code.
§46.8002. List of Administrative Errors.
Administrative errors include, but are not limited to, the following.
(1)-(9)
(No change.)
[
The facility uses a
daily census record that has not been approved by DHS. The DHS applies the
error to the total number of units reimbursed while using the unapproved daily
census record form.]
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
January 8, 1999.
TRD-9900085
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Proposed date of adoption: May 1, 1999
For further information, please call: (512) 438-3765
Subchapter C. Claims Payment
40 TAC §47.3906
The Texas Department of Human Services (DHS) proposes an
amendment to §47.3906, concerning claims payment reviews and audits,
in its Primary Home Care chapter. The purpose of the amendment is to delete
the use of an unapproved substitute form as an administrative error.
Eric M. Bost, commissioner, has determined that for the first five- year
period the proposed section will be in effect there will be no fiscal implications
for state or local government as a result of enforcing or administering the
section.
Mr. Bost also has determined that for each year of the first five years
the section is in effect the public benefit anticipated as a result of enforcing
the section will be to focus the administrative sanction on the collection
of required data, rather than on the process of obtaining DHS approval. There
will be no adverse economic effect on small businesses because this change
decreases the amount of fiscal sanctions that may be imposed. There is no
anticipated economic cost to persons who are required to comply with the proposed
section.
Questions about the content of the proposal may be directed to Frances
Barraza at (512) 438-3216 in DHS's Long Term Care Section. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-070,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas,
78714-9030, within 30 days of publication in the
Texas Register
.
The amendment is proposed under the Human Resources Code, Title
2, Chapters 22 and 32, which provides the department with the authority to
administer public and medical assistance programs and under Texas Government
Code §531.021, which provides the Health and Human Services Commission
with the authority to administer federal medical assistance funds.
The amendment implements §§22.001-22.030 and §§32.001-32.042
of the Human Resources Code.
§47.3906.Claims Payment Reviews and Audits.
(a)-(f)
(No change.)
(g)
List of administrative errors. Administrative errors include,
but are not limited to, the following.
(1)-(12)
(No change.)
[(13)
The provider agency uses a timesheet
that has not been approved by the department. The department applies the error
to the total number of units reimbursed while using an unapproved timesheet.]
(13)
[
(h)
(No change.)
(i)
Reimbursement for underpayments.
The department
reimburses the provider agency for any underpayments reflected in the audit
reports. The department may withhold the reimbursement of an underpayment
if the provider agency has an outstanding audit exception.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
January 8, 1999.
TRD-9900084
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Proposed date of adoption: May 1, 1999
For further information, please call: (512) 438-3765
The Texas Department of Human Services (DHS) proposes the repeal of
§48.2107, concerning rejected claims; §48.2809, concerning rejected
claims; and §48.6013, concerning rejected claims; and an amendment to
§48.2807, concerning provider claims payment, in its Community Care for
Aged and Disabled chapter. The purpose of the repeals and amendment is to
implement a business rule for the claims management system (CMS) project.
Under the CMS project, DHS and the Texas Department of Mental Health and Mental
Retardation have partnered with the National Heritage Insurance Company (NHIC)
to develop an automated business system to consolidate claims submission and
processing for 19 different long term care programs of the two agencies. The
proposed rule states that claims should be submitted within 180 days of service.
Eric M. Bost, commissioner, has determined that for the first five-year
period the repealed and amended sections are in effect there will be no fiscal
implications for state or local government as a result of enforcing or administering
the section.
Mr. Bost also has determined that for each year of the first five years
the repealed and amended sections are in effect the public benefit anticipated
as a result of enforcing the sections will be that the proposed rules support
the implementation of the Claims Management System, which will process claims
accurately, on time, within applicable program, accounting and Medicaid Management
Information System (MMIS) standards; be responsive to customers' needs; and
be readily adaptable to change. There will be no effect on small businesses
because the rule requires contractors to submit claims within 180 days of
the last day of service, but states that DHS has the option to pay claims
received after the 180-day time period. There is no economic effect for businesses,
large or small. The rule simply encourages contractors to submit claims in
a timely manner. There is no anticipated economic cost to persons who are
required to comply with the proposed sections.
Questions about the content of this proposal may be directed to Susan Syler
at (512) 438-3111 in DHS's Long Term Care Section. Written comments on the
proposal may be submitted to Supervisor, Rules and Handbooks Unit-080, Texas
Department of Human Services E-205, P.O. Box 149030, Austin, Texas, 78714-9030,
within 30 days of publication in the
Texas Register
.
Subchapter C. Medicaid Waiver Program for Persons with Related Conditions
40 TAC §48.2107
(Editor's note: The text of the following section proposed for
repeal will not be published. The section may be examined in the offices of
the Texas Department of Human Services or in the Texas Register office, Room
245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeal is proposed under the Human Resources
Code, Title 2, Chapters 22 and 32, which authorizes the department to administer
public and medical assistance programs; and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The repeal implements the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
§48.2107.Rejected Claims.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
January 11, 1999.
TRD-9900107
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Proposed date of adoption: April 1, 1999
For further information, please call: (512) 438-3765
40 TAC §48.2807
The amendment is proposed under the Human Resources Code,
Title 2, Chapters 22 and 32, which authorizes the department to administer
public and medical assistance programs; and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The amendment implements the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
§48.2807.Provider Claims Payment.
(a)
Bienvivir will receive preset capitation payments from
Medicaid based on the client's entitlement. The following conditions must
be met for payment to occur.
(1)-(3)
(No change.)
[(4)
An initial claim for services must
be received in the DHS provider services section within 95 calendar days of
the end of the month of service.]
(b)
(No change.)
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
January 11, 1999.
TRD-9900108
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Proposed date of adoption: April 1, 1999
For further information, please call: (512) 438-3765
40 TAC §48.2809
(Editor's note: The text of the following section proposed for
repeal will not be published. The section may be examined in the offices of
the Texas Department of Human Services or in the Texas Register office, Room
245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeal is proposed under the Human Resources
Code, Title 2, Chapters 22 and 32, which authorizes the department to administer
public and medical assistance programs; and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The repeal implements the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
§48.2809.Rejected Claims.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
January 11, 1999.
TRD-9900109
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Proposed date of adoption: April 1, 1999
For further information, please call: (512) 438-3765
40 TAC §48.6013
(Editor's note: The text of the following section proposed for
repeal will not be published. The section may be examined in the offices of
the Texas Department of Human Services or in the Texas Register office, Room
245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeal is proposed under the Human Resources
Code, Title 2, Chapters 22 and 32, which authorizes the department to administer
public and medical assistance programs; and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The repeal implements the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
§48.6013.Rejected Claims.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
January 11, 1999.
TRD-9900110
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Proposed date of adoption: April 1, 1999
For further information, please call: (512) 438-3765
40 TAC §48.6003, §48.6030
The Texas Department of Human Services (DHS) proposes amendments
to §48.6003, concerning client eligibility criteria, and to §48.6030,
concerning Home and Community Support Services (HCSS) general contracting
requirements, in its Community Care for Aged and Disabled chapter. The purpose
of the amendment to §48.6003 is to allow an individual's service plan
in the 1915(c) Medicaid waiver program to have the same cost limits as individuals
in nursing facilities, not to exceed 100% of the individual's actual Texas
Index for Level of Effort payment rate. The purpose of the amendment to §48.6030
is to establish HCSS agencies' qualifications for contracting with DHS to
provide Community Based Alternatives (CBA) services. The amendment deletes
the requirement for HCSS agencies to be licensed and certified. It maintains
the requirement that services must be provided through the licensed home health
category of licensure and requires the HCSS agency license to cover each county
specified in the DHS contract.
Eric M. Bost, commissioner, has determined that for the first five-year
period the proposed §48.6003 will be in effect there will be fiscal implications
for state government as a result of enforcing or administering the sections.
The effect on state government for the first five-year period the section
will be in effect is an estimated additional cost of $69,749 in fiscal year
(FY) 1999; $103,030 in FY 2000; $103,030 in FY 2001; $103,030 in FY 2002;
and $103,030 in FY 2003. The commissioner has also determined that for the
first five-year period the proposed §48.6030 will be in effect there
will be no fiscal implications for state government as a result of enforcing
or administering the sections. There will be no fiscal effect on local government
as a result of enforcing or administering the sections.
Mr. Bost also has determined that for each year of the first five years
the sections are in effect the public benefit anticipated as a result of enforcing
§48.6003 will be that some applicants with greater needs may qualify
for CBA services. There will be no effect on small businesses, because it
affects the CBA clients and not the agencies providing care to the clients.
The amendment increases the CBA client's service plan maximum from 95% to
100% of the Texas Index for Level of Effort payment rate. There is no anticipated
economic cost to persons who are required to comply with the proposed sections.
Mr. Bost also has determined that for each year of the first five years
the sections are in effect the public benefit anticipated as a result of enforcing
§48.6030 will be that HCSS agencies can provide CBA services through
their licensed home health category of licensure, which is more cost effective
than providing services under their licensed and certified category of licensure.
There will be no effect on small businesses, because it makes it easier for
agencies to contract with DHS to provide CBA services. The amendment deletes
the requirement for licensed and certified category of licensure as an HCSS
agency contracting requirement for the CBA program. There is no anticipated
economic cost to persons who are required to comply with the proposed sections.
Questions about the content of this proposal may be directed to Carolyn
Saras at (512) 438-5192 in DHS's Community Care Section. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-079,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030,
within 30 days of publication in the
Texas Register
.
The amendments are proposed under the Human Resources Code, Title
2, Chapters 22 and 32, which authorizes the department to administer public
and medical assistance programs; and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The amendments implement the Human Resources Code, §§22.001-
22.030 and §§32.001-32.042.
§48.6003. Client Eligibility Criteria.
(a)
To be determined eligible by the Texas Department of Human
Services (DHS) for the 1915(c) Medicaid waiver program provided as an alternative
to care in a nursing facility, an applicant must:
(1)-(4)
(No change.)
(5)
have an individual plan of care for waiver services
as specified in §48.6006 of this title (relating to Individual Plan of
Care for Waiver Services) whose cost does not exceed
100%
[
(6)-(10)
(No change.)
(b)-(e)
(No change.)
§48.6030. Home and Community Support Services Provider Qualifications [
To be qualified as a home and community support services (HCSS)
provider to deliver Community Based Alternatives (CBA) services under contract
with the Texas Department of Human Services (DHS), a HCSS agency must:
[
(1)
have a separate contract to
provide CBA services in each DHS region in which services are to be delivered;
(2)
have one parent or branch
office with the category of licensed home health which is physically located
in the DHS region in which CBA services are to be delivered;
(3)
deliver CBA services
through the licensed home health category of licensure;
[
be licensed by the Texas
Department of Health (TDH) as a Home and Community Support Service agency
to provide the following categories of service:]
[
licensed and certified home health services;
and]
[
licensed home health services; and]
(4)
have the counties
in the DHS contract for CBA services included in the identified service area
on file at the Texas Department of Health (TDH) with the current license;
and
(5)
[
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
January 8, 1999.
TRD-9900070
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Proposed date of adoption: April 1, 1999
For further information, please call: (512) 438-3765
40 TAC §48.6090
The Texas Department of Human Services (DHS) proposes an
amendment to §48.6090, concerning fiscal monitoring and recoupment, in
its Community Care for Aged and Disabled (CCAD) chapter. The purpose of the
amendment is to delete the use of an unapproved substitute form as an administrative
error.
Eric M. Bost, commissioner, has determined that for the first five- year
period the proposed section will be in effect there will be no fiscal implications
for state or local government as a result of enforcing or administering the
section.
Mr. Bost also has determined that for each year of the first five years
the section is in effect the public benefit anticipated as a result of enforcing
the section will be to focus the administrative sanction on the collection
of the required data, rather than on the process of obtaining DHS approval
for a substitute form. There will be no adverse economic effect on small businesses
because this change decreases the amount of fiscal sanctions that may be imposed.
There is no anticipated economic cost to persons who are required to comply
with the proposed section.
Questions about the content of the proposal may be directed to Frances
Barraza at (512) 438-3216 in DHS's Long Term Care Section. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-070,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030,
within 30 days of publication in the
Texas Register
.
The amendment is proposed under the Human Resources Code, Title
2, Chapters 22 and 32, which provides the department with the authority to
administer public and medical assistance programs and under Texas Government
Code §531.021, which provides the Health and Human Services Commission
with the authority to administer federal medical assistance funds.
The amendment implements §§22.001-22.030 and 32.001-32.042 of
the Human Resources Code.
§48.6090.Fiscal Monitoring and Recoupment.
(a)
Administrative errors. A recoupment of 12% of the paid
unit rate is the administrative error exception for services billed on an
hourly basis. It represents the administrative portion of the rate. Administrative
errors are applied to the documentation reviewed and are not extrapolated.
Administrative errors include, but are not limited to, the items in paragraphs
(1)-(2) of this subsection:
(1)
administrative errors on the documentation of services
delivered form [
(A)-(K)
(No change.)
[
The provider agency uses a
form that has not been approved by DHS. DHS applies the error to the total
number of units reimbursed while using something other than documentation
of services delivered form or an approved facsimile.]
(L)
[
(M)
[
(2)
(No change.)
(b)
Financial errors. A reduction of 100% of the paid unit
rate is the financial error exception. This exception is applied to the units
of service on the documentation reviewed. This exception is not extrapolated.
Financial errors include, but are not limited to, the following:
(1)
DHS reimburses the provider agency for services, but the
documentation of services delivered form, or [
(2)-(4)
(No change.)
(5)
DHS reimburses the provider agency for hours that
exceed the total number of hours recorded on the documentation of services
delivered form or [
(6)-(12)
(No change.)
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
January 8, 1999.
TRD-9900086
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Proposed date of adoption: May 1, 1999
For further information, please call: (512) 438-3765
40 TAC §49.9
The Texas Department of Human Services (DHS) proposes an
amendment to §49.9, concerning billings and claims payment, in its Contracting
for Community Care Services chapter. The purpose of the amendment is to implement
a business rule for the claims management system (CMS) project. Under the
CMS project, DHS and the Texas Department of Mental Health and Mental Retardation
have partnered with the National Heritage Insurance Company (NHIC) to develop
an automated business system to consolidate claims submission and processing
for 19 different long term care programs of the two agencies. The proposed
rule states that claims should be submitted within 180 days of service.
Eric M. Bost, commissioner, has determined that for the first five-year
period the section is in effect there will be no fiscal implications for state
or local government as a result of enforcing or administering the section.
Mr. Bost also has determined that for each year of the first five years
the section is in effect the public benefit anticipated as a result of enforcing
the section will be that the proposed rule supports the implementation of
the Claims Management System, which will process claims accurately, on time,
within applicable program, accounting and Medicaid Management Information
System (MMIS) standards; be responsive to customers' needs; and be readily
adaptable to change. There will be no effect on small businesses, because
the rule requires contractors to submit claims within 180 days of the last
day of service, but states that DHS has the option to pay claims received
after the 180-day time period. There is no economic effect for businesses,
large or small. The rule simply encourages contractors to submit claims in
a timely manner. There is no anticipated economic cost to persons who are
required to comply with the proposed sections.
Questions about the content of this proposal may be directed to Susan Syler
at (512) 438-3111 in DHS's Long Term Care Section. Written comments on the
proposal may be submitted to Supervisor, Rules and Handbooks Unit-080, Texas
Department of Human Services E-205, P.O. Box 149030, Austin, Texas, 78714-9030,
within 30 days of publication in the
Texas Register
.
The amendment is proposed under the Human Resources Code, Title
2, Chapters 22 and 32, which authorizes the department to administer public
and medical assistance programs; and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The amendment implements the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
§49.9.Billings and Claims Payment.
(a)-(b)
(No change.)
(c)
A provider agency is entitled to payment if:
(1)-(11)
(No change.)
(12)
the initial monthly claim for services is received
by DHS's claim processor within 180
[
(A)
All payments are subject to availability
of funds as provided by law.
(B)
Claims and adjustments received after
the 180-day time period may be paid upon approval by DHS. An excessive number
of late claims or adjustments may subject the service provider's claims procedures
to audit by DHS.
(C)
In the event that Medicaid eligibility
for benefits is established after provision of services, the 180-day period
for submission of claims will start on the date eligibility is established;
(13)-(14)
(No change.)
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
January 11, 1999.
TRD-9900111
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Proposed date of adoption: April 1, 1999
For further information, please call: (512) 438-3765
Chapter 732.
Contracted Services
Subchapter L. Contract Administration
Chapter 45.
Community Living Assistance and Support Services
or the prior approved facsimile
]:
(L)
The provider agency uses a
form that has not been approved by DHS. DHS applies the error to the total
number of units reimbursed while using something other than documentation
of services delivered form or an approved facsimile.]
(M)
] DHS reimburses the provider
agency for nursing, therapies, psychological, habilitation, out-of-home respite,
in-home respite, adaptive aids/vehicle modifications or home modifications
but a valid authorization individual service plan (ISP) form, pages 1-2 and
all pertinent attachments signed by the case manager, are missing for the
period reimbursed to the agency. DHS applies the error to the total number
of units of nursing, psychological therapies, habilitation, out-of-home respite,
in-home respite, and adaptive aids/vehicular modifications claimed and not
covered by an valid ISP.
(N)
] DHS reimburses the provider
agency for nursing services, and there is no other documentation available
that the nurse provided billable nursing services during the visit.
approved
] facsimile, is missing for the period
for which services are reimbursed. DHS applies the error to the total number
of units documented on the time sheet.
approved
] facsimile. DHS applies the error to
the total number of units reimbursed in excess of the units recorded on the
time sheet. If the sum of the daily total of hours does not equal what is
written in the monthly total blank, the lesser of the two totals is used to
calculate the total number of hours subject to the error.
Chapter 46.
Licensed Personal Care Facilities Contracting with the Texas Department of Human Services to Provide Residential Care Services
(10)
Chapter 47.
Primary Home Care
(14)
] The department reimburses
the provider agency for services, but a valid prior approval/confirmation
of services form is missing for the period reimbursed by the agency. The department
applies the error to the total number of units reimbursed and not covered
by a valid prior approval/confirmation of services form.
Chapter 48.
Community Care for Aged and Disabled
Subchapter G. Program for All-Inclusive Care for the Elderly (PACE)
Subchapter J. 1915(c) Medicaid Home and Community-based Waiver Services for Aged and Disabled Adults Who Meet Criteria for Alternatives to Nursing Facility Care
95%
] of the individual's actual Texas Index for Level of Effort payment
rate;
General Contracting Requirements ].
To contract with the Texas Department of Human Services (DHS) to provide
home and community support services under the Nursing Facility Waiver Program,
a legal entity or one of its divisions must:
]
(1)
(A)
(B)
(2)
] be authorized by the
secretary of state to do business in the State of Texas (if an out-of-state
corporation).
or the prior approved facsimile
]:
(L)
(M)
] DHS reimburses the provider
agency for nursing, therapies, personal assistance services, or in-home respite,
but a valid individual service plan, pages 1-3 and all pertinent attachments,
signed by the case manager, is missing for the period reimbursed by the agency.
DHS applies the error to the total number of units of nursing, therapies,
personal assistance services, or in-home respite, claimed and not covered
by a valid individual service plan.
(N)
] DHS reimburses the provider
agency for nursing services and there is no other documentation available
to determine whether the nurse provided billable nursing services during the
visit.
approved
] facsimile,
is missing for the period for which services are reimbursed. DHS applies the
error to the total number of units documented on the time sheet.
approved
] facsimile. DHS applies the error to
the total number of units reimbursed in excess of the units recorded on the
time sheet. If the sum of the daily total of hours does not equal what is
written in the monthly total blank, the lesser of the two totals is used to
calculate the total number of hours subject to the error.
Chapter 49.
Contracting for Community Care Services
in state office within 95
] days after the end of the service month
.
[
;
]
The following provisions apply:
Part XIX.
Texas Department of Protective and Regulatory Services