Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354 - MEDICAID HEALTH SERVICES
Subchapter A - PURCHASED HEALTH SERVICES
Division 1 - MEDICAID PROCEDURES FOR PROVIDERS
Section 354.1005 - Unauthorized Charges

Universal Citation: 1 TX Admin Code § 354.1005

Current through Reg. 50, No. 13; March 28, 2025

(a) An eligible provider must certify that no charges beyond reimbursement paid under the Texas Medicaid Program for a covered service or any function incidental to the provision of a covered service, have been, or will be, billed to an eligible recipient.

(b) Within the provisions cited in § 354.1131 of this chapter (relating to Payments to Eligible Providers), an eligible provider may not bill or take other recourse against an eligible recipient for claims denied as a result of an error attributed to the provider.

(c) For purposes of subsection (a) of this section, functions incidental to the provision of a covered service include:

(1) signing, completing, or providing a copy of a health assessment form, such as a physical examination form required for the eligible recipient's enrollment in school or participation in school or other activities;

(2) providing a copy of a medical record requested:
(A) by or on behalf of any health care practitioner for purposes of medical care or treatment of the eligible recipient;

(B) under Texas Health and Safety Code § 161.202;

(C) as a supplement to a form described in paragraph (1) of this subsection; or

(D) by an eligible recipient, for any reason, for the first time in a one-year period; and

(3) providing a copy of any subsequent amendment, supplement, or correction to a medical record under paragraph (2) of this subsection.

(d) An eligible provider may bill or otherwise charge an eligible recipient for providing a copy of a medical record not described in subsection (c)(2) of this section if the:

(1) eligible provider provided one copy of the medical record at no charge to the eligible recipient within one year before the request for an additional copy;

(2) medical record described in paragraph (1) of this subsection has not been amended, supplemented, changed, or corrected and contains the same documentation as the medical record requested under this subsection; and

(3) provider complies with state and federal law, including 22 TAC § 165.2(relating to Medical Record Release and Charges) and 45 C.F.R. 164.524.

(e) For purposes of this section, "medical record" includes a record with the elements described in 22 TAC § 165.1(a) (relating to Medical Records). The term also includes a copy of a medical record created by another health care practitioner and in the possession of the eligible provider to whom a request for release of records has been made.

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