Current through Reg. 49, No. 52; December 27, 2024
(a) HHSC pays a
contractor for a claim for services that meets the requirements described in
subsection (b) of this section.
(b)
A contractor must ensure a claim for services is:
(1) for a service that has been provided by a
contractor;
(3) complete and
accurate;
(4) submitted within 12
months after one of the following, whichever is later:
(A) the last day of the month in which the
service was provided, the adaptive aid or medical supply delivered, or the
minor home modification completed; or
(B) the date the individual's eligibility for
the service was determined;
(5) for a type and amount of service that is
authorized by HHSC;
(6) for a
service provided to an individual who is eligible for the service;
(7) except as provided in HHSC rules
governing services provided under the contract, for a service provided to an
individual whose authorization for services has not been suspended or
terminated by HHSC;
(8) for a
service provided during a time period authorized by HHSC;
(9) for a service provided during the term
of, and in accordance with, the contract, this subchapter, and HHSC rules
governing services provided under the contract;
(10) supported by records required by the
contract and HHSC rules governing services provided under the
contract;
(11) for a service
provided by a qualified service provider in accordance with HHSC rules
governing services provided under the contract;
(12) for a service ordered by a qualified
practitioner, if required by the contract or HHSC rules governing services
provided under the contract;
(13)
submitted in accordance with procedures required by HHSC rules governing
services provided under the contract and by the claims administrator;
and
(14) not for a service that a
source other than HHSC would have paid for if the contractor had submitted a
proper, complete, and timely request for payment to the other source.
(c) As used in subsection (b)(11)
and (12) of this section, the terms "qualified service provider" and "qualified
practitioner" do not include a person whose health-related license has been
suspended or revoked or who has been excluded from participation in a program
administered under Title V, XVIII, XIX, or XX of the Social Security
Act.
(d) HHSC denies a claim for
services that does not meet the requirements in subsection (b) of this section
and HHSC rules governing services provided under the contract. If HHSC denies a
claim for services, a contractor may request and receive an administrative
hearing.
(e) If a contractor or
HHSC determines that the contractor received payment for a claim for services
that does not meet the requirements in subsection (b) of this section and HHSC
rules governing services provided under the contract:
(1) the contractor may submit a corrected
claim for services to allow HHSC to adjust amounts paid to a contractor, even
if it is after the 12-month period described in subsection (b)(4) of this
section; or
(2) HHSC recoups funds
paid to the contractor in accordance with §
49.533
of this chapter (relating to Recoupment).
(f) If a claim for services is denied by HHSC
, the contractor that submitted the claim may submit a corrected claim within
the 12-month period described in subsection (b)(4) of this section.
(g) HHSC may adjust amounts paid to a
contractor after the 12-month period described in subsection (b)(4) of this
section.
