| (a) Reviews conducted under the TMRP, TEFRA, and facility-specific
per diem methodology may result in denials of claims. HHSC notifies
the hospital in writing of the denial decision and instructs the claims
administrator to recoup payment. If a hospital claim is denied for
lack of medical necessity or for being provided in an inappropriate
setting, HHSC considers for denial physician and/or non-physician
Medicaid provider claims associated with the hospital admission or
service when such claims can be identified and are deemed to be the
result of inappropriate admission orders. Physicians and/or non-physician
providers are notified in writing if the claim for professional services
is denied. The written notification of denial explains the appeal
process. Types of denials are:
(1) Admission and days of stay denials. A physician
consultant under contract with HHSC makes all decisions regarding
medical necessity, cause of readmission, and appropriateness of setting.
(2) Technical denials. HHSC issues a technical denial
when a hospital fails to make the complete medical record available
for review within specified time frames. These services may not be
rebilled on an outpatient basis.
(A) For on-site reviews, if the complete medical record
is not made available during the on-site review, HHSC issues a preliminary
technical denial at that time. The hospital is allowed 60 calendar
days from the date of the exit conference to provide the complete
medical record to HHSC. If the complete medical record is not received
by HHSC within this time frame, HHSC issues a final technical denial.
If HHSC requests a copy of the medical record in writing, and the
copy is not received within the specified time frame, HHSC issues
a preliminary technical denial by certified mail or fax machine. The
hospital has 60 calendar days from the date of the notice to submit
the complete medical record. If the complete medical record is not
received by HHSC within this time frame, HHSC issues a final technical
denial.
(B) For mail-in reviews, HHSC requests copies of medical
records in writing. If HHSC does not receive the complete medical
record within the specified time frame, HHSC issues a preliminary
technical denial by certified mail or fax machine. The hospital has
60 calendar days from the date of the notice to submit the complete
medical record. If HHSC does not receive the complete medical record
within this specified time frame, HHSC issues a final technical denial.
(3) Readmission denial. If it is determined that the
services provided in the second or subsequent admissions were the
direct result of a premature discharge or should have been provided
in the first or previous admission, HHSC denies the admission in question.
(4) Day outlier denial. If it is determined that any
days qualifying as outlier days during the admission were not medically
necessary, HHSC denies those days.
(5) Cost outlier denial. If it is determined that services
delivered were not medically necessary, not ordered by a physician
and/or authorized non-physician, not rendered or billed appropriately,
or not substantiated in the medical record, HHSC denies those services.
(b) When an admission denial or day of stay denial
is issued, HHSC directs the claims administrator to recoup payment.
If a hospital claim is denied for lack of medical necessity or for
being provided in an inappropriate setting, HHSC considers for denial
physician and/or non-physician Medicaid provider claims associated
with the hospital admission or service when such claims can be identified
and are deemed to be the result of inappropriate admission orders.
HHSC makes an exception in the case of TMRP hospitals if the patient
was placed in observation and HHSC notified the hospital that it may
submit a revised outpatient claim solely for medically necessary outpatient
services provided during the Texas Medicaid Provider Procedures Manual
(TMPPM), or any subsequent provider manuals, defined observation period.
A physician's order for observation must be present in the physician's
orders to document that the patient was placed in outpatient observation.
The hospital must submit the revised outpatient claim and a copy of
HHSC's notification letter to the claims administrator at the address
indicated in the notification letter. The claims administrator must
receive the outpatient claim and copy of the notification letter within
120 calendar days of the date of the notification letter. The claims
administrator may consider payment for the medically necessary services
provided during the TMPPM-defined observation period. The hospital
may provide observation services in any part of the hospital where
a patient can be assessed, monitored, and treated.
|
| Source Note: The provisions of this §371.206 adopted to be effective June 14, 1989, 14 TexReg 2624; amended to be effective February 1, 1991, 16 TexReg 232; amended 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 November 22, 1995, 20 TexReg 9274; amended to be effective March 25, 1996, 21 TexReg 2079; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000,25 TexReg1308; amended to be effective March 30, 2003, 28 TexReg 2481; amended to be effective January 11, 2004, 29 TexReg 357; amended to be effective April 14, 2004, 29 TexReg 3611; amended to be effective January 1, 2014, 38 TexReg 9479; amended to be effective May 1, 2016, 41 TexReg 2941 |
