Texas Register
(29 TexReg 741). The text of the
rule will be republished. Section 371.206 is being amended to comply with
the federal claim deadlines associated with the fiscal agent arrangement.
The Texas Medicaid program transition from a health insuring agent arrangement
to a fiscal agent arrangement necessitates that change.
The Commission adopts the amendment to §371.206(b), with the change,
in order to be consistent with the Commission's previously adopted appeals
rules. The adopted rule is effective twenty days after submission to the Secretary
of State.
The Commission received a written comment concerning §371.206(b) during
the 30-day comment period from January 30, 2004 to February 29, 2004. A summary
of the written comment and the Commission's response follows.
Comment: The Commission received a comment from the Appeals Unit, Medicaid/CHIP,
Resolution Services, HHSC, requesting that the time frame for the hospital
to submit an outpatient claim be changed from the proposed ninety-five days
to one hundred twenty days, in order to be consistent with the Commission's
previously adopted appeals rules.
Response: The Commission agrees with the comment by the Appeals Unit, Medicaid/CHIP,
Resolution Services, HHSC, and will revise the proposed ninety-five day time
frame to a one hundred twenty day time frame, in order to be consistent with
the Commission's previously adopted appeal rules. The revision to a one hundred
twenty day time frame remains consistent with the applicable federal claim
payment deadlines.
The amendment is adopted under authority granted to HHSC by §531.033,
Texas Government Code, which provides the Executive Commissioner of HHSC with
broad rulemaking authority, and under §531.021 (a), Texas Government
Code, which authorizes HHSC to administer the federal medical assistance (Medicaid)
program in Texas.
§371.206.Denials and Recoupments for Texas Medical Review Program (TMRP), Tax Equity and Fiscal Responsibility Act (TEFRA), and LoneSTAR Select II Contracted Hospitals.
(a)
Reviews conducted under the Texas Medical Review Program
(TMRP), Tax Equity and Fiscal Responsibility Act (TEFRA), and LoneSTAR Select
II Contracting programs may result in denials of claims. The Texas Health
and Human Services Commission (Commission) will notify the hospital in writing
of the denial decision, and instruct the claims administrator to recoup payment.
If a hospital claim is denied for lack of medical necessity or for being provided
in an inappropriate setting, the Commission will consider for denial physician
claims associated with the hospital admission or service when such claims
can be identified and are deemed to be the result of inappropriate admission
orders. Types of denials are:
(1)
Admission and days of stay denials. A physician consultant
under contract with the Commission makes all decisions regarding medical necessity,
cause of readmission, and appropriateness of setting.
(2)
Technical denials. The Commission will issue a technical
denial when a hospital fails to make the complete medical record available
for review within specified time frames. These services may not be rebilled
on an outpatient basis.
(A)
For on-site reviews, if the complete medical record is
not made available during the on-site review, the Commission will issue a
preliminary technical denial at that time. The hospital is allowed sixty calendar
days from the date of the exit conference to provide the complete medical
record to the Commission. If the complete medical record is not received by
the Commission within this time frame, the Commission will issue a final technical
denial. If the Commission requests a copy of the medical record in writing,
and the copy is not received within the specified time frame, the Commission
will issue a preliminary technical denial by certified mail or fax machine.
The hospital has sixty calendar days from the date of the notice to submit
the complete medical record. If the complete medical record is not received
by the Commission within this time frame, the Commission will issue a final
technical denial.
(B)
For mail-in reviews, the Commission will request copies
of medical records in writing. If the Commission does not receive the complete
medical record within the specified time frame, the Commission will issue
a preliminary technical denial by certified mail or fax machine. The hospital
has sixty calendar days from the date of the notice to submit the complete
medical record. If the Commission does not receive the complete medical record
within this specified time frame, the Commission will issue a final technical
denial.
(3)
Readmission denial. If it is determined that the services
provided in the second or subsequent admissions were the direct result of
a premature discharge or should have been provided in the first or previous
admission, the Commission will deny the admission in question
(4)
Day outlier denial. If it is determined that any days qualifying
as outlier days during the admission were not medically necessary, the Commission
will deny those days.
(5)
Cost outlier denial. If it is determined that services
delivered were not medically necessary, not ordered by a physician, not rendered
or billed appropriately, or not substantiated in the medical record, the Commission
will deny those services.
(b)
When an admission denial or day of stay denial is issued,
the Commission will direct the claims administrator to recoup payment. If
a hospital claim is denied for lack of medical necessity or for being provided
in an inappropriate setting, the Commission will consider for denial physician
claims associated with the hospital admission or service when such claims
can be identified and are deemed to be the result of inappropriate admission
orders. The Commission will make an exception in the case of TMRP hospitals
if the patient was originally placed in observation, and the hospital has
been notified by the Commission that they may submit a revised outpatient
claim solely for medically necessary outpatient services provided during the
observation period. A physician's order for observation must be present in
the physician's orders to document that the patient was originally placed
in outpatient observation. The hospital must submit the revised outpatient
claim and a copy of the Commission's notification letter to the claims administrator
at the address indicated in the notification letter. The claims administrator
must receive the outpatient claim and copy of the notification letter within
one hundred twenty calendar days of the date of the notification letter. The
claims administrator may consider payment for the medically necessary services
provided during the twenty-four hour observation period. The hospital may
provide observation services in any part of the hospital where a patient can
be assessed, monitored and treated.
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 March 25, 2004.
TRD-200402121
Steve Aragón
General Counsel
Texas Health and Human Services Commission
Effective date: April 14, 2004
Proposal publication date: January 30, 2004
For further information, please call: (512) 424-6576