Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY
Subchapter C - UTILIZATION REVIEW
Section 371.201 - Case Selection Process
Universal Citation: 1 TX Admin Code § 371.201
Current through Reg. 50, No. 13; March 28, 2025
(a) HHSC selects TMRP cases for review by a statistically valid random sampling methodology and/or focused case selection. Cases consist of paid inpatient claims for diagnosis-related groups (DRGs), which may include:
(1) readmissions up to 30 days;
(2) ambulatory surgical procedures billed on inpatient claims;
(3) questionable admissions or claims coding identified by other entities;
(4) admissions identified through HHSC's quality review program as potential quality of care concerns;
(5) DRG payments made to freestanding rehabilitation facilities;
(6) day or cost outlier payments; or
(7) any other DRG or claims submission errors.
(b) HHSC selects TEFRA and facility-specific per diem methodology cases for review by a statistically valid random sampling methodology and/or focused case selection. Cases consist of paid inpatient claims for admissions to children's hospitals and freestanding psychiatric facilities.
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