Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 266 - MEDICAID HOSPICE PROGRAM
Subchapter B - UTILIZATION REVIEW
Section 266.223 - Recoupment
Universal Citation: 26 TX Admin Code ยง 266.223
Current through Reg. 49, No. 38; September 20, 2024
(a) HHSC recoups from a hospice under 40 TAC § 49.533(relating to Recoupment) amounts paid to the hospice for a service if the hospice has not complied with the requirements described in this chapter.
(b) Recoupment amounts for hospice eligibility and level of service utilization reviews.
(1) HHSC recoups 100 percent of the hospice
claim amount for the dates of service reviewed when the hospice fails to
provide HHSC the following:
(A) the Individual
Election/Cancellation/Update Form completed in accordance with § 266.205
of this subchapter (relating to Election of Hospice Care);
(B) the Physician Certification of Terminal
Illness Form completed in accordance with § 266.203 of this subchapter
(relating to Certification of Terminal Illness);
(C) a physician narrative that meets the
minimum criteria in § 266.203(c)(2) of this subchapter; or
(D) if the individual receiving hospice
services is in an election period after the subsequent 90-day election period,
documentation of the face-to-face assessment required by § 266.203(d) of
this subchapter.
(2) HHSC
recoups 50 percent of the hospice claim amount for the dates of service
reviewed when the hospice fails to provide nursing assessments and
notes.
(3) HHSC recoups 30 percent
of the hospice claim amount for the dates of service reviewed when the hospice
fails to provide HHSC supporting clinical documentation related to the terminal
illness and the progression of the terminal illness, including signs and
symptoms, anthropometric measurements, weights, oral intake, and laboratory and
diagnostic testing.
(4) HHSC
recoups 25 percent of the hospice claim amount for the dates of service
reviewed when the hospice fails to provide HHSC with documentation of an
initial plan of care and updated plans of care as required by § 266.211 of
this subchapter (relating to Continuous Home Care) and § 266.221 of this
subchapter (relating to Hospice Documentation Requirements).
(c) Recoupment amounts for CHC reviews.
(1) HHSC recoups 100 percent of the
CHC claim amount for the dates of service reviewed when the hospice fails to
provide HHSC the following:
(A) documentation
establishing that a crisis existed;
(B) a physician's order for CHC; or
(C) documentation establishing that the
individual received care for at least 8 hours within a 24-hour day during the
period of crisis.
(2)
HHSC recoups 50 percent of the CHC claim for the dates of service reviewed when
the hospice fails to provide HHSC documentation establishing that the hospice
agency employees provided skilled nursing care for more than 50 percent of the
period of crisis.
(3) HHSC recoups
25 percent of the CHC claim amount for the dates of service reviewed when the
hospice fails to provide HHSC the following as required by § 266.211 of
this subchapter and § 266.221 of this subchapter:
(A) the plan of care specific to the
identified crisis and dated before the initiation of CHC;
(B) documentation that is legible to a reader
other than the author, clear, complete, signed or initialed, and dated in
accordance with hospice policy and currently accepted standards of practice;
or
(C) documentation that is signed
and appropriately authenticated, which means the hospice is able to
authenticate each handwritten and electronic signature of a primary author who
has reviewed and approved the entry.
(4) HHSC recoups 10 percent of the CHC claim
amount for the dates of service reviewed when the hospice fails to provide HHSC
documentation of the discussion of temporary alternate placement required by
§ 266.211(6) of this subchapter, including documentation of the IDT
meeting and who participated in the IDT meeting.
(d) Other. HHSC will recoup the amount of any overpayment discovered.
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