A person is subject to administrative actions or sanctions
if the person submits, or causes to be submitted, a claim for payment
by the Medicaid or other HHS program:
(1) for an item or service for which the person knew
or should have known the claim or cost report was false or fraudulent;
(2) for an item or service that was not provided as
claimed;
(3) for an item or service that requires prior authorization,
prior order, or prescription, where prior authorization, prior order,
or prescription was not properly obtained, including where prior authorization,
prior order, or prescription requirements were met by misrepresentation
or omission;
(4) for an item or service that requires the name and
National Provider Number of the supervising, ordering, or referring
person for prior authorization, where the correct name and National
Provider Number of the supervising, ordering, or referring person
were not provided;
(5) based on a code that would result in greater payment
than the code applicable to the item or service that was actually
provided;
(6) for an item or service that was not coded, bundled,
or billed in accordance with standards required by statute, regulation,
contract, Medicaid or other HHS program policy or provider manual,
and that, if used, has the potential of increasing any individual
or state provider payment rate or fee;
(7) for an item or service that was not reimbursable
by, permitted by, or associated with the Medicaid or other HHS program,
including an item or service substituted without authorization by
the Medicaid or other HHS program and a prescription drug substituted
without authorization by an HHS program;
(8) for any order or prescription in which a false
statement, misrepresentation, or omission of pertinent facts was made
by the ordering or prescribing person on a claim, attachments to a
claim, medical record, documentation used to adjudicate a claim for
payment or to support representations on cost reports, used by the
provider to show the medical necessity, or on documents used to establish
fees, daily payment rates, or vendor payments;
(9) for an item or service where the charges for that
item or service exceed the usual and customary fee the person charges
to the public, privately insured persons, or private-pay persons for
the same item or service, including a claim submitted under Title
XVIII (Medicare);
(10) for an item or service where the charges or costs
for that item or service were discounted for the public, privately
insured persons, or private-pay persons for the same item or service,
including a claim submitted under Title XVIII (Medicare);
(11) for an item or service that is furnished, prescribed,
or otherwise ordered or presented by a person that is excluded, terminated,
or otherwise prohibited from participation in an HHS program or any
state or federally funded health care program, except an order or
prescription that was:
(A) written before the exclusion or termination of
a physician or other practitioner legally authorized to write a prescription;
and
(B) delivered within 30 days of the effective date
of such exclusion or termination;
(12) for a home health service for which no in-person
evaluation of the recipient was performed within the 12-month period
preceding the date of the order or other authorization for the home
health service;
(13) for durable medical equipment for which the physician,
physician assistant, nurse practitioner, clinical nurse specialist,
or certified nurse-midwife that ordered or otherwise authorized the
durable medical equipment has failed to certify on the order or authorization
that he or she conducted an in-person evaluation of the recipient
within the 12-month period preceding the date of the order or other
authorization;
(14) for an item or service for which the provider
knowingly made, used, or caused the making or use of a false record
or statement material to an obligation to pay or transmit money or
property to this state under the Medicaid program, or knowingly concealed
or knowingly and improperly avoided or decreased an obligation to
pay or transmit money or property to this state under the Medicaid
program;
(15) for an item or service that constitutes a violation
of §32.039(b) or §36.002 of the Texas Human Resources Code;
(16) for an item or service rendered to a child who
was not accompanied by an authorized adult or who was accompanied
by the provider or its affiliate to treatment; or
(17) for damages, costs, or penalties collected or
assessed by the OIG.
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