1 Tex. Admin. Code § 371.206 - Denials and Recoupments for TMRP, TEFRA Hospitals, and Facility-Specific Per Diem Methodology Reviews
(a)
Reviews conducted under the TMRP, TEFRA, and facility-specific per diem
methodology may result in denials of claims. HHSC notifies the hospital in
writing of the denial decision and instructs 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, HHSC considers for denial physician
and/or non-physician Medicaid provider 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. Physicians and/or non-physician
providers are notified in writing if the claim for professional services is
denied. The written notification of denial explains the appeal process. Types
of denials are:
(1) Admission and days of
stay denials. A physician consultant under contract with HHSC makes all
decisions regarding medical necessity, cause of readmission, and
appropriateness of setting.
(2)
Technical denials. HHSC issues 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, HHSC issues a
preliminary technical denial at that time. The hospital is allowed 60 calendar
days from the date of the exit conference to provide the complete medical
record to HHSC. If the complete medical record is not received by HHSC within
this time frame, HHSC issues a final technical denial. If HHSC requests a copy
of the medical record in writing, and the copy is not received within the
specified time frame, HHSC issues a preliminary technical denial by certified
mail or fax machine. The hospital has 60 calendar days from the date of the
notice to submit the complete medical record. If the complete medical record is
not received by HHSC within this time frame, HHSC issues a final technical
denial.
(B) For mail-in reviews,
HHSC requests copies of medical records in writing. If HHSC does not receive
the complete medical record within the specified time frame, HHSC issues a
preliminary technical denial by certified mail or fax machine. The hospital has
60 calendar days from the date of the notice to submit the complete medical
record. If HHSC does not receive the complete medical record within this
specified time frame, HHSC issues 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, HHSC denies 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, HHSC denies those days.
(5) Cost outlier denial. If it is determined
that services delivered were not medically necessary, not ordered by a
physician and/or authorized non-physician, not rendered or billed
appropriately, or not substantiated in the medical record, HHSC denies those
services.
(b) When an
admission denial or day of stay denial is issued, HHSC directs 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, HHSC
considers for denial physician and/or non-physician Medicaid provider 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.
HHSC makes an exception in the case of TMRP hospitals if the patient was placed
in observation and HHSC notified the hospital that it may submit a revised
outpatient claim solely for medically necessary outpatient services provided
during the Texas Medicaid Provider Procedures Manual (TMPPM), or any subsequent
provider manuals, defined observation period. A physician's order for
observation must be present in the physician's orders to document that the
patient was placed in outpatient observation. The hospital must submit the
revised outpatient claim and a copy of HHSC'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 120 calendar days of the date of the notification letter. The
claims administrator may consider payment for the medically necessary services
provided during the TMPPM-defined observation period. The hospital may provide
observation services in any part of the hospital where a patient can be
assessed, monitored, and treated.
Notes
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