1 Tex. Admin. Code § 353.504 - Review of Managed Care Organization's Records
(a) Immediately upon request, the Health and
Human Services Commission, Office of Inspector General (HHSC-OIG), Office of
the Attorney General-Medicaid Fraud Control Unit (OAG-MFCU) and OAG, Office of
the Attorney General-Civil Medicaid Fraud Division (OAG-CMFD), and the United
States Health and Human Services, Office of Inspector General (HHS-OIG) may
review the records of a managed care organization (MCO) to determine compliance
with this subchapter.
(b) Upon
receipt of a record review request from any state or federal agency authorized
to conduct compliance, regulatory, or program integrity functions, an MCO must:
(1) At no charge to the entities identified
in subsection (a) of this section, provide the records requested by a properly
identified agent of any state or federal agency authorized to conduct
compliance, regulatory, or program integrity functions on the provider, person,
MCO, or the services rendered by the provider or person within 24 hours of the
request.
(2) An exception to the 24
hours stated in paragraph (1) of this subsection may be made when the OIG or
another state or federal agency representative reasonably believes that the
requested records are about to be altered or destroyed or that the request may
be completed at the time of the request and/or in less than 24 hours.
(c) The request for record review
may include, but is not limited to:
(1)
clinical medical or dental patient records;
(2) other records pertaining to the
patient;
(3) any other records of
services provided to Medicaid or other health and human services program
recipients and payments made for those services;
(4) documents related to diagnosis,
treatment, service, lab results, charting;
(5) billing records, invoices, documentation
of delivery items, equipment, or supplies;
(6) radiographs and study models related to
orthodontia services;
(7) business
and accounting records with backup support documentation;
(8) statistical documentation;
(9) computer records and data; and
(10) contracts with providers and
subcontractors.
(d)
Failure to produce the records or make the records available for the purpose of
reviewing, examining, and securing custody of the records may result in HHSC
imposing contractual remedies or HHSC-OIG imposing sanctions against the MCO as
described in Chapter 371, Subchapter G of this title (relating to Legal Action
Relating to Providers of Medical Assistance), or both remedies and
sanctions.
Notes
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