Texas Administrative Code

Texas Administrative Code

TITLE 1	ADMINISTRATION
PART 15	TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 371	MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY
SUBCHAPTER C	UTILIZATION REVIEW
RULE §371.201	Case Selection Process

(a) HHSC selects TMRP cases for review by a statistically valid random sampling methodology and/or focused case selection. Cases consist of paid inpatient claims for diagnosis-related groups (DRGs), which may include:

(1) readmissions up to 30 days;

(2) ambulatory surgical procedures billed on inpatient claims;

(3) questionable admissions or claims coding identified by other entities;

(4) admissions identified through HHSC's quality review program as potential quality of care concerns;

(5) DRG payments made to freestanding rehabilitation facilities;

(6) day or cost outlier payments; or

(7) any other DRG or claims submission errors.

(b) HHSC selects TEFRA and facility-specific per diem methodology cases for review by a statistically valid random sampling methodology and/or focused case selection. Cases consist of paid inpatient claims for admissions to children's hospitals and freestanding psychiatric facilities.

Source Note: The provisions of this §371.201 adopted to be effective January 1, 1993, 17 TexReg 8457; transferred effective September 1, 1993, as published in the Texas Register January 28, 1994, 19 TexReg 589; amended to be effective July 27, 1994, 19 TexReg 5493; amended to be effective November 22, 1995, 20 TexReg 9274; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000, 25 TexReg 1308; amended to be effective March 30, 2003, 28 TexReg 2481; amended to be effective January 1, 2014. 38 TexReg 9479; amended to be effective May 1, 2016, 41 TexReg 2941