Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 511 - LIMITED SERVICES RURAL HOSPITALS
Subchapter C - OPERATIONAL REQUIREMENTS
Section 511.75 - Billing Requirements

Universal Citation: 26 TX Admin Code § 511.75

Current through Reg. 49, No. 52; December 27, 2024

(a) A limited services rural hospital (LSRH) shall adopt, implement, and enforce a policy to ensure that the hospital complies with Texas Health and Safety Code (HSC) §311.002.

(b) An LSRH shall adopt, implement, and enforce a policy to ensure that the LSRH complies with HSC §311.0025.

(c) An LSRH shall comply with the itemized bill requirements under HSC §185.002.

(d) An LSRH shall comply with the following balance billing requirements.

(1) An LSRH may not violate a law that prohibits the hospital from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.

(2) An LSRH shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO (relating to Disclosures by Out-of-Network Providers) to the extent that subchapter applies to the LSRH.

(e) A complaint submitted to the Texas Health and Human Services Commission's Complaint and Incident Intake relating to billing must specify the patient for whom the bill was submitted.

(1) Upon receiving a complaint warranting an investigation, the Texas Health and Human Services Commission (HHSC) shall send the complaint to the LSRH and request the LSRH to conduct an internal investigation.

(2) Within 30 days of the LSRH's receipt of the complaint, the LSRH shall submit to HHSC:
(A) a report outlining the LSRH's investigative process;

(B) the resolution or conclusions reached by the LSRH with the patient, third party payor, or complainant; and

(C) corrections, if any, in the LSRH's policies or protocols that were made as a result of its investigative findings.

(3) In addition to the LSRH's internal investigation, HHSC may also conduct an investigation to audit any billing and patient records of the LSRH.

(4) HHSC shall inform, in writing, a complainant who identifies him or herself by name and address:
(A) of the receipt of the complaint;

(B) if the complainant's allegations are potential violations of the Act or this chapter warranting an investigation;

(C) whether the complaint will be investigated by HHSC;

(D) if the complaint was referred to the LSRH for internal investigation;

(E) whether and to whom the complaint will be referred;

(F) of the results of the LSRH's investigation and the LSRH's resolution with the complainant; and

(G) of HHSC's findings if an on-site audit investigation was conducted.

(5) HHSC shall refer investigative reports of billing by health care professionals who have provided improper, unreasonable, or medically or clinically unnecessary treatments or billed for treatments that were not provided to the appropriate licensing agency.

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