| (a) Program provider reimbursement.
(1) HHSC pays a program provider for services as described
in this paragraph.
(A) HHSC pays for community support, nursing, in-home
respite, respite, day habilitation, in-home day habilitation, employment
assistance, supported employment, professional therapies, and CFC
PAS/HAB in accordance with the reimbursement rate for the specific
service.
(B) HHSC pays for adaptive aids, minor home modifications,
and dental treatment based on the actual cost of the item or service
and, if requested, a requisition fee in accordance with the TxHmL
Program Billing Requirements available on the HHSC website.
(C) HHSC pays for CFC ERS based on the actual cost
of the service not to exceed the reimbursement rate ceiling for CFC
ERS.
(2) To be paid for the provision of a service, a program
provider must submit a service claim that meets the requirements in
40 TAC §49.311 (relating to Claims Payment) and the TxHmL Program
Billing Requirements or the CFC Billing Requirements for HCS and TxHmL
Program Providers.
(3) If an individual's TxHmL Program services or CFC
services are suspended or terminated, a program provider must not
submit a claim for services provided during the period of the individual's
suspension or after the termination except the program provider may
submit a claim for a service provided on the first calendar day of
the suspension or termination.
(4) If a program provider submits a claim for an adaptive
aid that costs $500 or more or for a minor home modification that
costs $1,000 or more, the claim must be supported by a written assessment
from a licensed professional specified by HHSC in the TxHmL Program
Billing Requirements and other documentation as required by the TxHmL
Program Billing Requirements.
(5) HHSC does not pay a program provider for a service
or recoups any payments made to the program provider for a service
if:
(A) the individual receiving the service was, at the
time the service was provided, ineligible for the TxHmL Program or
Medicaid benefits, or was an inpatient of a hospital, nursing facility,
or ICF/IID;
(B) the service was not included on the signed and
dated IPC of the individual in effect at the time the service was
provided;
(C) the service was not provided in accordance with
the TxHmL Program Billing Requirements or the CFC Billing Requirements
for HCS and TxHmL Program Providers;
(D) the service was not documented in accordance with
the TxHmL Program Billing Requirements or the CFC Billing Requirements
for HCS and TxHmL Program Providers;
(E) the program provider did not comply with 40 TAC §49.305
(relating to Records);
(F) the claim for the service was not prepared and
submitted in accordance with the TxHmL Program Billing Requirements
or the CFC Billing Requirements Guidelines for HCS and TxHmL Program
Providers;
(G) the program provider did not have the documentation
described in subsection (a)(4) of this section;
(H) before including employment assistance on an individual's
IPC, the program provider did not ensure and maintain documentation
in the individual's record that employment assistance was not available
to the individual under a program funded under §110 of the Rehabilitation
Act of 1973, as amended (29 U.S.C. §701 et seq.) or under a program
funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401
et seq.);
(I) before including supported employment on an individual's
IPC, the program provider did not ensure and maintain documentation
in the individual's record that supported employment was not available
to the individual under a program funded under the Individuals with
Disabilities Education Act (20 U.S.C. §1401 et seq.);
(J) HHSC determines that the service would have been
paid for by a source other than the TxHmL Program;
(K) the service was provided by a service provider
who did not meet the qualifications to provide the service as described
in the TxHmL Program Billing Requirements or the CFC Billing Requirements
for HCS and TxHmL Program Providers;
(L) the service was not provided in accordance with
a signed and dated IPC meeting the requirements set forth in §262.301
of this subchapter (relating to IPC Requirements);
(M) the service was not provided in accordance with
the PDP or the implementation plan;
(N) the service was provided before the individual's
date of enrollment into the TxHmL Program;
(O) for community support, the service was not provided
in accordance with a transportation plan and §262.5(a)(16) of
this chapter (relating to Description of TxHmL Program Services);
(P) the service was not provided; or
(Q) for CFC PAS/HAB, in-home day habilitation, and
in-home respite, if the service claim for the service did not match
the EVV visit transaction as required by 1 TAC §354.4009(a)(4)
(relating to Requirements for Claims Submission and Approval).
(6) A program provider must refund to HHSC any overpayment
made to the program provider within 60 days after the program provider's
discovery of the overpayment or receipt of a notice of such discovery
from HHSC, whichever is earlier.
(7) Except as provided in paragraph (8) of this subsection,
if HHSC approves an LOC requested in accordance with §262.104(b)(3)
of this chapter (relating to LOC Determination), HHSC pays a program
provider for services provided to an individual for a period of not
more than 180 calendar days after the individual's previous ID/RC
Assessment expires.
(8) If HHSC determines that an ID/RC Assessment was
submitted more than 180 calendar days after the expiration date of
the previous ID/RC Assessment because of circumstances beyond a program
provider's control, HHSC may pay the program provider for a period
of more than 180 calendar days after the individual's previous ID/RC
Assessment expires.
(9) HHSC does not withhold payments to a program provider
if a LIDDA fails to enter information from an individual's renewal
IPC and the program provider continues to provide services in accordance
with the most recent IPC authorized by HHSC.
(b) Provider fiscal compliance reviews.
(1) HHSC conducts provider fiscal compliance reviews
to determine a program provider is in compliance with:
(A) this chapter;
(B) the TxHmL Program Billing Requirements;
(C) the CFC Billing Requirements for HCS and TxHmL
Program Providers;
(D) 40 TAC Chapter 49, Subchapter C; and
(E) the program provider's Community Services Contract-Provider
Agreement.
(2) HHSC conducts provider fiscal compliance reviews
in accordance with the Provider Fiscal Compliance Review Protocol
set forth in the TxHmL Program Billing Requirements and the CFC Billing
Requirements for HCS and TxHmL Program Providers. As a result of a
provider fiscal compliance review, HHSC may:
(A) recoup payments from a program provider; and
(B) based on the amount of unverified claims, require
a program provider to develop and submit, in accordance with HHSC's
instructions, a corrective action plan that improves the program provider's
billing practices.
(3) A corrective action plan required by HHSC in accordance
with paragraph (2)(B) of this subsection must:
(A) include:
(i) the reason the corrective action plan is required;
(ii) the corrective action to be taken;
(iii) the person responsible for taking each corrective
action; and
(iv) a date by which the corrective action will be
completed that is no later than 90 calendar days after the date the
program provider is notified the corrective action plan is required;
(B) be submitted to HHSC within 30 calendar days after
the date the program provider is notified the corrective action plan
is required; and
(C) be approved by HHSC before implementation.
(4) Within 30 calendar days after HHSC receives a corrective
action plan, HHSC notifies the program provider if HHSC approves the
corrective action plan or if the plan requires changes.
(5) If HHSC requires a program provider to develop
and submit a corrective action plan in accordance with paragraph (2)(B)
of this subsection and the program provider requests an administrative
hearing for the recoupment in accordance with §262.602 of this
chapter (relating to Program Provider's Right to Administrative Hearing),
the program provider is not required to develop or submit a corrective
action plan while a hearing decision is pending. HHSC notifies the
program provider if the requirement to submit a corrective action
plan or the content of such a plan changes based on the outcome of
the hearing.
(6) If a program provider does not submit a corrective
action plan or complete a required corrective action within the time
frames described in paragraph (3) of this subsection, HHSC may impose
a vendor hold on payments due to the program provider until the program
provider takes the corrective action.
(7) If a program provider does not submit a corrective
action plan or complete a required corrective action within 30 calendar
days after the date a vendor hold is imposed in accordance with paragraph
(6) of this subsection, HHSC may terminate the contract.
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