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 371.226 - Calculation of Overpayments and Underpayments

Universal Citation: 1 TX Admin Code § 371.226

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

(a) For each specific RUG that is found to be in error during the review and for which no timely and complete reconsideration review was requested, OIG may direct the reclassification of the RUG and recover an overpayment, or reimburse an underpayment, after the reconsideration request deadline has passed.

(b) For each specific RUG for which a reconsideration review was granted and for which no hearing was requested, OIG may direct the reclassification of the RUG and recover an overpayment after the hearing request deadline has passed.

(c) For each specific RUG for which a timely request for a hearing is made, OIG may direct the reclassification of the RUG and recover an overpayment after a final decision regarding the appeal is issued.

(d) OIG may recover overpayments and reimburse underpayments after due process has been concluded for all RUGs in the review.

(e) OIG may use statistical sampling and extrapolation for nursing facility utilization review cases in accordance with § 371.35 of this title (relating to Use of Statistical Sampling and Extrapolation).

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