1 TAC §371.204, §371.208
The Health and Human Services Commission (HHSC) proposes
to amend Chapter 371, §371.204 and §371.208, concerning Medicaid
and other Health and Human Services Fraud and Abuse Program Integrity. Chapter
371 describes the Hospital Screening Criteria for Texas Medical Review Program
(TMRP), Tax Equity and Fiscal Responsibility Act (TEFRA), and LoneSTAR Select
II Contract Reviews and Appeals Related to Utilization Review Department Review
Decisions.
Background and Justification
Currently, §371.204, Hospital Screening Criteria for Texas Medical
Review Program (TMRP), Tax Equity and Fiscal Responsibility Act (TEFRA), and
LoneSTAR Select II Contract Reviews, makes references to utilization review
criteria. The Office of the Inspector General performs Utilization Reviews
of inpatient hospital stays based on "physician-developed and physician-approved
inpatient hospital" criteria. The amendment is necessary to establish new
criteria for utilization review because the existing criteria is no longer
available for use.
Rule 371.208, the Appeals Related to Utilization Review Department Decisions,
allows a hospital that receives a notice from HHSC of an adverse decisions
regarding medical necessity of admission, to appeal to the responsible area
within HHSC. The written notification of the adverse decision sets out the
time frame for the appeal process. HHSC is revising language to clarify the
appropriate section within the agency that is responsible for reviewing the
appeal.
Section-by-Section Summary
Rule 371.204, Hospital Screening Criteria for Texas Medical Review Program
(TMRP), Tax Equity and Fiscal Responsibility Act (TEFRA), and LoneSTAR Select
II Contract Reviews, describes the criteria used for utilization review of
inpatient hospital stays. The revisions to the rule include replacing references
from "physician-developed and physician-approved inpatient hospital" criteria
to "recognized evidence-based guideline" utilization review criteria.
Rule 371.208, Appeals Related To Utilization Review Department Review Decisions,
describes the provider's appeal process of utilization review decisions made
by HHSC. The proposed amendment changes references from "Department" to "Unit"
and from "Resolution Services, Medical/Administrative Appeals" to the "responsible
area in HHSC."
Fiscal Note
Tom Suehs, Deputy Commissioner for Financial Services, has determined that
during the initial implementation period the proposed amendment is in effect
there will be a cost to the state. For state fiscal years 2006 - 2010, the
state will incur a cost of $65,600 per year. For state fiscal year 2006, the
state may experience a cost of $786,400, a federal cost of $1,213,600 and
total cost of $2,000,000. Local governments will not incur additional costs.
The proposed amendment will not have an affect on the local health and human
service agencies.
Small and Micro-Business Impact Analysis
Mr. Suehs has also determined that there will be no effect on small businesses
or micro-businesses to comply with this amendment as proposed. This was determined
by interpretation of the rule that small businesses and micro-businesses will
not be required to alter their business practices in order to comply with
the proposed amendment. There are no anticipated economic costs to persons
who are required to comply with the amendment as proposed. There is no anticipated
negative impact on local employment.
Public Benefit
Mr. Brian Flood, Inspector General, has determined that for the initial
implementation period the amendment is in effect, the public will benefit
from adoption of the amendment. The anticipated public benefit, as a result
of implementing the amendment, will be a more efficient utilization review
process due to the modification to the guideline criteria.
Regulatory Analysis
HHSC has determined that the proposed amendment is not a "major environmental
rule," as defined by §2001.0225 of the Texas Government Code. "Major
environmental rule" is defined to mean a rule the specific intent of which
is to protect the environment or reduce risk to human health from environmental
exposure and that may adversely affect, in a material way, the economy, a
sector of the economy, productivity, competition, jobs, the environment or
the public health and safety of a state or a sector of the state. The proposed
amendment is not specifically intended to protect the environment or reduce
risks to human health from environmental exposure.
Takings Impact Assessment
HHSC has determined that the proposed amendment does not restrict or limit
an owner's right to his or her property that would otherwise exist in the
absence of government action and, therefore, does not constitute a taking
under §2007.043 of the Government Code.
Public Comment
Written comments on the proposal may be submitted to Judy Knobloch, Quality
Nurse Specialist, Office of the Inspector General Division, Texas Health and
Human Services Commission, P.O. Box 85200, MC-1324, Austin, Texas 78708-5200,
within 30 days of publication of this proposal in the
Texas Register
.
Public Hearing
A public hearing is scheduled for May 24, 2006, at 2:00 p.m. in the Lone
Star Conference Room at 11209 Metric Boulevard, Building H, Austin, Texas.
Persons requiring further information, special assistance, or accommodations
should contact Kyna Belcher at (512) 491-1884.
To comply with federal regulations, a copy of the proposal is being sent
to each Texas Department of Aging and Disability Services (DADS) office where
it will be available for public review upon request.
Statutory Authority
The amendments are proposed under the Texas Government Code, §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking authority;
the Human Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the Texas Medicaid program;
and Government Code §2001.006, which allows state agencies to adopt rules
in preparation for the implementation of legislation. HHSC has the authority
to obtain any information or technology necessary to enable the office to
meet its responsibilities, §531.102(a) OFFICE OF INSPECTOR GENERAL.
The proposed rules affect the Human Resources Code, Chapter 32, and the
Texas Government Code, Chapter 531. No other statutes, articles, or codes
are affected by the proposed amendment.
§371.204.Hospital Screening Criteria for Texas Medical Review Program (TMRP), Tax Equity and Fiscal Responsibility Act (TEFRA), and LoneSTAR Select II Contract Reviews.
(a)
The Texas Health and Human Services Commission (Commission)
uses
recognized evidence-based guidelines for
[
physician-developed
and physician-approved
] inpatient hospital screening criteria.
Non-physician
[
The criteria included Indicators for Hospitalization
(IH) and Treatment (T) criteria. Nonphysician
] reviewers use the criteria
as guidelines for the initial approval or for the referral of inpatient reviews
for medical necessity decisions. If the [
IH or T
] criteria are
not met, or if the
non-physician
[
nonphysician
] reviewer
has any questions concerning the appropriateness of coding or quality of care,
the nonphysician reviewer will refer the medical record to a physician consultant
under contract with the Commission for a decision. Even if the [
IH or
T
] criteria are met, the physician consultant may determine that an
inpatient admission was not medically necessary and the Commission will issue
an admission denial. 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. A physician consultant may determine that an inpatient admission
was not medically necessary if a physician admitted a patient in observation
status and the patient was discharged within twenty-four hours from that outpatient
status.
(b)
For the purposes of the TMRP, TEFRA, and LoneSTAR Select
II Contract reviews, medical necessity means that the patient has a condition
requiring treatment that can be safely provided only in the inpatient setting.
§371.208.Appeals Related To Utilization Review Department Review Decisions
If a hospital receives notification from the Texas Health and Human
Services Commission (HHSC) Utilization Review
Unit
[
Department
] of an adverse decision regarding medical necessity of admission, days
of stay, diagnosis related group (DRG) validation, or a final technical denial,
the hospital may appeal to [
the
] HHSC [
Resolution Services,
Medical/Administrative Appeals Unit
]. The written notification of adverse
decision will set out the
responsible area and
time frame within
which the appeal must be received by [
the
] HHSC
. The Texas
Medicaid Policy and Procedure Manual provides additional information on the
appeal process.
[
Resolution Services, Medical/Administrative Appeals
Unit.
]
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 May 1, 2006.
TRD-200602408
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: June 11, 2006
For further information, please call: (512) 424-6576