| (a) In an audit of a provider or FMSA conducted by
a managed care organization (MCO), the MCO must limit the review of
EVV visit transactions to those that occurred during the 24 months
prior to the audit.
(b) If, based on an audit or investigation of a provider
or FMSA, an MCO identifies a deficiency related to an EVV visit transaction
that is not fraud or abuse and the MCO decides to recoup an overpayment
because of the deficiency, the MCO must give the provider or FMSA
written notice of the MCO's intent to recoup overpayments not later
than the 30th day after the date the audit or investigation is completed.
(c) An MCO must include the following in the written
notice required by subsection (b) of this section:
(1) a description of the basis for the intended recoupment;
(2) if the basis of the intended recoupment is an EVV
visit transaction, the specific EVV visit transaction and associated
claim that are the basis of the intended recoupment;
(3) if the basis of the intended recoupment is a missing
EVV visit transaction, the claim for which there is no associated
EVV visit transaction;
(4) that the MCO must receive a response to the notice
from the provider or FMSA no later than the 30th day after the date
the provider or FMSA receives the written notice, if the provider
or FMSA intends to respond;
(5) the specific number of days allowed to correct
and explain the deficiency before the MCO begins any efforts to collect
overpayments, which must be no fewer than 60 days from the notice
date;
(6) the process by which the provider or FMSA should
communicate with and send information to the MCO about the EVV visit
transactions that are the basis of the intended recoupment;
(7) the provider's or FMSA's option to seek an informal
resolution with the MCO of the intended recoupment; and
(8) the MCO's process for the provider or FMSA to appeal
the intended recoupment.
(d) A corrected deficiency is one that a provider or
FMSA makes by doing one or both of the following:
(1) performing visit maintenance to correct an EVV
visit transaction in accordance with HHSC EVV policy; or
(2) correcting and resubmitting a claim in accordance
with MCO policies and procedures.
(e) An MCO may recoup an overpayment only if a provider
or FMSA:
(1) does not correct the deficiency and does not appeal
the alleged overpayment; or
(2) appeals the alleged overpayment and the final decision
from the appeal is favorable to the MCO.
(f) If an MCO determines that a deficiency related
to an EVV visit transaction is fraud or abuse, the MCO must comply
with §353.1454 of this subchapter (relating to Due Process Procedures
to Recoup an Overpayment Because of a Discovery of Fraud or Abuse).
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