Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 353 - MEDICAID MANAGED CARE
Subchapter Q - PROCESS TO RECOUP CERTAIN OVERPAYMENTS
Section 353.1454 - Due Process Procedures to Recoup an Overpayment Because of a Discovery of Fraud or Abuse
Universal Citation: 1 TX Admin Code ยง 353.1454
Current through Reg. 49, No. 38; September 20, 2024
(a) If a managed care organization (MCO) decides to recoup an overpayment from a provider or FMSA because of a discovery of fraud or abuse as permitted by § RSA 353.505 of this chapter (relating to Recovery of Funds), the MCO must have due process procedures that include the following:
(1)
written notice to the provider or FMSA of the MCO's intent to recoup
overpayments that includes the following:
(A)
a description of the basis for the intended recoupment;
(B) the specific claims that are the basis of
the intendedrecoupment;
(C) the
process by which the provider or FMSA should send information to the MCO about
claims that are the basis of the intended recoupment;
(D) the provider's or FMSA's option to seek
an informal resolution with the MCO of the intended recoupment; and
(E) the MCO's process for the provider or
FMSA to appeal the intended recoupment;
(2) a process for the provider or FMSA to
seek informal resolution; and
(3) a
process for the provider or FMSA to appeal the intended recoupment.
(b) An MCO may recoup an overpayment only if a provider or FMSA:
(1)
does not appeal the alleged overpayment; or
(2) appeals the alleged overpayment and the
final decision from the appeal is favorable to the MCO.
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