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) adopts new §19.2609
without changes to the proposed text published in the January 22, 1999, issue
of the
Texas Register
(24 TexReg 373). The
text will not be republished.
Justification for the new section is that a business rule for the new Claims
Management System, a joint undertaking of the Texas Department of Human Services,
the Texas Department of Mental Health and Mental Retardation, and the National
Heritage Insurance Company (NHIC), requires that claims be submitted within
180 days of service. The department made the rule change to conform to the
business rule.
The new section will function by implementing 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 rule states that claims should
be submitted within 180 days of service.
The department received a comment regarding adoption of the amendment from
the Texas Health Care Association. A summary of the comment and the department's
response follows.
Comment: The Texas Health Care Association (THCA) believes the proposed
rules appear to directly violate the Austin Court of Appeals ruling in the
Texas Department of Human Services, et al. v. Christian Care Centers, Inc.,
litigation of 1991. In its ruling, the court determined that the department
has no authority to withhold payment for care given simply because of late
submission of paperwork. In fact, Medicaid and Medicare law presumes that
providers will be paid for care given.
The Texas Legislature, in its appropriations bill, assumes a two-year window
for payment of bills owed by the state for services provided. In fact, the
Legislature provides a mechanism for payment of claims older than two years
through its "miscellaneous claims" legislation (House Bill 2778, 75th Legislative
Session (1997)). Together, these bills clearly show that the Legislature intends
to pay the legitimate claims for goods and services provided to the state.
THCA disagrees with the department's claim that there will be no fiscal
impact resulting from the implementation of this rule. THCA suggests that
the department calculate the total dollar amount of claims paid in the last
year on claims in excess of 180 days. The result would be a good estimate
of the fiscal impact that this rule would have on providers, if implemented.
The federal regulations at 42 CFR 447.45(d) acknowledge that a 12-month
window for claims submission is acceptable. Although one reason for a claim
exceeding 180 days can be a lack of timeliness on the provider's part in submitting
the claim, there are many, many times that this lack of timeliness is entirely
beyond the control of the provider. Private insurance and Medicare Part A
eligibility denials and the subsequent appeals processes, for example, can
easily exceed two years. In addition, Medicare has a new payment system and
we do not know how long it will take to process claims and denials. This proposed
rule would restrict cash flow and result in undue hardship on providers for
actions that are often entirely beyond their control.
Many nursing facilities admit people who are applying for SSI; many of
these people have no income and cannot apply for Medicaid until the SSI process
is approved. This process takes at least six months to complete, and can take
much longer if documentation is difficult to find. (In the proposed rule it
states that claims submitted after 180 days may be paid after approval by
DHS. The proposed rule further states that the 180-day billing period begins
when eligibility is established.) The potential for extreme fiscal impact
for every nursing facility is tremendous. The proposed rules also state that
"an excessive number of late claims or adjustments may subject the service
provider's claims procedures to audit by DHS." The Medicaid Eligibility worker
reviews all patient files every six months; this review can result in a reduction
or increase of patient applied income. When the facility receives this document
an adjustment is necessary. As you can see this could take over 180 days.
Submission of a "claim" by a nursing facility is not a simple process.
It involves submission of several types of forms such as 3652, 3618, and 3619
plus the new CMS Data Entry. An error on any one of these forms could be considered
as "failure to submit a claim."
A major concern is the fact that there is no process, procedure, or guidelines
set forth in the draft rules regarding the approval process by DHS for late
submitted claims. Another major concern is that TDHS is not required in the
rule to give notice to the facility that reimbursement is going to cease.
In summary, this proposed rule might violate a court ruling that TDHS has
no authority to withhold payment for care given simply because of late submission
of paperwork. Also, this proposed rule would have a negative fiscal impact
on providers and violate legislative intent. If a nursing facility provides
reimbursable services, the department should pay for the service. I appreciate
the opportunity to provide these comments.
Response: The department does not agree with the comment. The proposed
rule does not give DHS the authority to withhold payment; in fact, it specifically
allows TDHS to pay late claims. The 180-day deadline in the rule is for purposes
of encouraging timely submission of claims, which benefits both the department
and the provider.
The commenter's concern about the length of time it takes to establish
Medicaid eligibility is specifically addressed by the rule, which states,
"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."
The new section is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
8, 1999.
TRD-9903338
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: January 22, 1999
For further information, please call: (512) 348-3765
The Texas Department of Human Services (DHS) adopts the repeal of
§§41.1-41.5, 41.201, 41.301, 41.302, 41.401-41.403, 41.501-41.503,
41.601, 41.701-41.704, 41.801, and 41.802, without changes to the proposed
text published in the April 16, 1999, issue of the
Texas Register
(24 TexReg 3046). The text will not be republished.
Justification for the repeals is to delete obsolete rules.
The repeals will function by deleting obsolete material.
The department received no comments regarding adoption of the repeals.
Subchapter A. Out-of-State Vendor Payments on Behalf of Texas Residents
40 TAC §§41.1-41.5
The repeals are adopted 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 repeals implement the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903379
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §41.201
The repeal is adopted under the Human Resources Code, Title
2, Chapters 22 and 32, which authorizes the department to administer public
and medical assistance pro- grams; 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903380
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §41.301, §41.302
The repeals are adopted under the Human Resources Code, Title
2, Chapters 22 and 32, which authorizes the department to administer public
and medical assistance pro- grams; 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 repeals implement the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903381
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §§41.401-41.403
The repeals are adopted under the Human Resources Code, Title
2, Chapters 22 and 32, which authorizes the department to administer public
and medical assistance pro- grams; 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 repeals implement the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903382
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §§41.501-41.503
The repeals are adopted under the Human Resources Code, Title
2, Chapters 22 and 32, which authorizes the department to administer public
and medical assistance pro- grams; 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 repeals implement the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903383
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §41.601
The repeal is adopted under the Human Resources Code, Title
2, Chapters 22 and 32, which authorizes the department to administer public
and medical assistance pro- grams; 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903384
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §§41.701-41.704
The repeals are adopted under the Human Resources Code, Title
2, Chapters 22 and 32, which authorizes the department to administer public
and medical assistance pro- grams; 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 repeals implement the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903385
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §41.801, §41.802
The repeals are adopted under the Human Resources Code, Title
2, Chapters 22 and 32, which authorizes the department to administer public
and medical assistance pro- grams; 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 repeals implement the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903386
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
The Texas Department of Human Services (DHS) adopts the repeal of
§§43.1, 43.11, 43.21, 43.31, 43.41, 43.51, 43.61, 43.71, 43.81,
43.91, and 43.101, without changes as proposed and published in the April
16, 1999, issue of the
Texas Register
(24
TexReg 3049). The text will not be republished.
Justification for the repeals is to delete obsolete rules.
The repeals will function by deleting obsolete material.
The department received no comments regarding adoption of the repeals.
Subchapter A. Management Responsibilities
40 TAC §43.1
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903387
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §43.11
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903388
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §43.21
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903389
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §43.31
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903390
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §43.41
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903391
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §43.51
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903392
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §43.61
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903393
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §43.71
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903394
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §43.81
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903395
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §43.91
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903396
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
40 TAC §43.101
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
9, 1999.
TRD-9903397
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: April 16, 1999
For further information, please call: (512) 438-3765
The Texas Department of Human Services (DHS) adopts the repeal of
§48.2107, §48.2809, and §48.6013, and an amendment to §48.2807,
without changes to the proposed text published in the January 22, 1999, issue
of the
Texas Register
(24 TexReg 376).
Justification for the repeals and the amendment is that a business rule
for the new Claims Management System, a joint undertaking of the Texas Department
of Human Services, the Texas Department of Mental Health and Mental Retardation,
and the National Heritage Insurance Company (NHIC), requires that claims be
submitted within 180 days of service. The department made the rule change
to conform to the business rule.
The amendment will function by implementing 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 rule states that claims should
be submitted within 180 days of service.
The department received no comments regarding adoption of the proposal.
Subchapter C. Medicaid Waiver Program for Persons with Related Conditions
40 TAC §48.2107
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
8, 1999.
TRD-9903339
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: January 22, 1999
For further information, please call: (512) 438-3765
40 TAC §48.2807
The amendment is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
8, 1999.
TRD-9903340
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: January 22, 1999
For further information, please call: (512) 438-3765
40 TAC §48.2809
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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
8, 1999.
TRD-9903341
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: January 22, 1999
For further information, please call: (512) 438-3765
40 TAC §48.6013
The repeal is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
8, 1999.
TRD-9903342
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: January 22, 1999
For further information, please call: (512) 438-3765
40 TAC §49.9
The Texas Department of Human Services (DHS) adopts an amendment
to §49.9 without changes to the proposed text published in the January
22, 1999, issue of the
Texas Register
(24
TexReg 379). The text will not be republished.
Justification for the amendment is that a business rule for the new Claims
Management System, a joint undertaking of the Texas Department of Human Services,
the Texas Department of Mental Health and Mental Retardation, and the National
Heritage Insurance Company (NHIC), requires that claims be submitted within
180 days of service. The department made the rule change to conform to the
business rule.
The amendment will function by implementing 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 rule states that claims should
be submitted within 180 days of service.
The department received a comment regarding adoption of the amendment from
the Texas Association for Home Care. A summary of the comment and the department's
response follows.
Comment: The Texas Association for Home Care, Inc., opposes the statement
in §49.9 that "all payments are subject to availability of funds as provided
by law." In the review process, it was stated by Department staff that there
are contracts which state a maximum number of hours of service or dollars
to be billed. Also, there are instances where billings may be settled after
the end of the department's fiscal year, in which case legislative approval
may be necessary. In order to address these circumstances, the first provision
in the proposed rule which we are objecting to should be deleted. The second
provision should be reworded to state " claims and adjustments received after
the 180-day time period, or exceeding contract limits, may be paid upon approval
by DHS, subject to availability of funds as provided by law." This would ensure
the provider which does bill timely and within their contracted amount will
get paid for services rendered in good faith.
Response: The department will retain the statement "all payments are subject
to availability of funds as provided by law." This is merely a statement of
fact. The department will retain the second provision: "Claims and adjustments
received after the 180-day time period may be paid upon approval by DHS."
This rule sets a time limit for submitting claims. The provision merely provides
that DHS may approve late claims for payment. There may be a number of reasons
why this would occur and there is no reason to list any one reason.
The amendment is adopted 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June
8, 1999.
TRD-9903343
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: July 1, 1999
Proposal publication date: January 22, 1999
For further information, please call: (512) 438-3765
Chapter 106.
Contract Administration
Subchapter A. Acquisition of Client Goods and Services
Chapter 41.
Utilization Review
Subchapter B. Health Insuring Agent
Subchapter C. Implementation Procedures for Nursing Facilities
Subchapter D. Skilled Nursing Facility Procedural Guide
Subchapter E. Intermediate Care Facility Procedural Guide
Subchapter F. Utilization Review Committees
Subchapter G. Long-Term Care Unit Procedures
Subchapter H. Level-of-Care Criteria
Chapter 43.
Utilization Control
Subchapter B. Exception Management
Subchapter C. Program
Subchapter D. Health Care Standards
Subchapter E. Educational Programs
Subchapter F. Review of Pharmaceutical Services
Subchapter G. Review of New Drug Applications
Subchapter H. Therapeutic Classification of Drugs
Subchapter I. Monitoring Drug Laws, Regulations, and Marketing Procedures
Subchapter J. Research, Development, and Application of Quantitative Techniques
Subchapter K. Quantitative Analysis in Developing Criteria
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
Chapter 49.
Contracting for Community Care Services
Part II.
Texas Rehabilitation Commission