Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 353 - MEDICAID MANAGED CARE
Subchapter F - SPECIAL INVESTIGATIVE UNITS
Section 353.501 - Purpose

Universal Citation: 1 TX Admin Code ยง 353.501

Current through Reg. 49, No. 38; September 20, 2024

(a) This subchapter implements the Health and Human Services Commission's (HHSC), Office of Inspector General (OIG) authority to approve annually, each managed care organization (MCO) plan to prevent and reduce waste, abuse, and fraud. This authority is granted by Chapter 531, Subchapter C, Government Code, § RSA 531.113.

(b) An MCO that provides or arranges for the provision of health care services or dental services to an individual under the Medical Assistance Program (Medicaid), must arrange for a special investigative unit to investigate fraudulent claims and other types of program abuse by recipients and providers. An MCO may choose to:

(1) establish and maintain the special investigative unit within the MCO; or

(2) contract with another entity for the investigation.

(c) An MCO must:

(1) develop a plan to prevent and reduce waste, abuse, and fraud;

(2) submit the plan annually to the HHSC-OIG for approval each year the MCO is enrolled with the State of Texas; and

(3) submit the plan 90 days before the start of the State fiscal year.

(d) If HHSC-OIG does not approve the initial plan to prevent and reduce waste, abuse, and fraud, the MCO must resubmit the plan to HHSC-OIG within 15 working days of receiving the denial letter, which will explain the deficiencies. If the plan is not resubmitted within the time allotted, the MCO will be in default and remedies or sanctions may be imposed.

(e) If the MCO elects to contract with another entity for the investigation of fraudulent claims and other types of program abuse as referenced in subsection (b)(2) of this section, the MCO must comply with all requirements of Title 42, §438.230 of the Code of Federal Regulations.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.