|(a) This subchapter implements the Health and Human
Services Commission's (HHSC), Office of Inspector General (OIG) authority
to approve annually, each managed care organization (MCO) plan to
prevent and reduce waste, abuse, and fraud. This authority is granted
by Chapter 531, Subchapter C, Government Code, §531.113.
(b) An MCO that provides or arranges for the provision
of health care services or dental services to an individual under
the Medical Assistance Program (Medicaid), must arrange for a special
investigative unit to investigate fraudulent claims and other types
of program abuse by recipients and providers. An MCO may choose to:
(1) establish and maintain the special investigative
unit within the MCO; or
(2) contract with another entity for the investigation.
(c) An MCO must:
(1) develop a plan to prevent and reduce waste, abuse,
(2) submit the plan annually to the HHSC-OIG for approval
each year the MCO is enrolled with the State of Texas; and
(3) submit the plan 90 days before the start of the
State fiscal year.
(d) If HHSC-OIG does not approve the initial plan to
prevent and reduce waste, abuse, and fraud, the MCO must resubmit
the plan to HHSC-OIG within 15 working days of receiving the denial
letter, which will explain the deficiencies. If the plan is not resubmitted
within the time allotted, the MCO will be in default and remedies
or sanctions may be imposed.
(e) If the MCO elects to contract with another entity
for the investigation of fraudulent claims and other types of program
abuse as referenced in subsection (b)(2) of this section, the MCO
must comply with all requirements of Title 42, §438.230 of the
Code of Federal Regulations.