| (IV) If the result in subclause (III) of this clause
is less than the APPS effective rate for this period, HHSC will set
the result in subclause (III) of this clause as the new final base
rate for this period;
(V) The prospective rate described in clause (iii)
of this subparagraph will be determined by adjusting the new final
base rate from subclause (IV) of this clause in accordance with paragraph
(4) of this subsection to determine the effective rate.
(VI) The new final base rate from subclause (IV) of
this clause and subsequent effective rates will not apply to claims
for services provided prior to the implementation date described in
clause (iii) of this subparagraph.
(ii) State initiated reviews will be based on a determined
twelve (12) month time period and the most recent cost data received
in accordance with paragraph (9) of this subsection. For any provider
filing a Low Utilization Cost Report with Medicare in accordance with
paragraph (9) of this subsection, upon request by HHSC, the provider
must complete and submit the forms and worksheets described in paragraph
(8)(A) of this subsection for the fiscal years ending within the determined
twelve (12) month time period, even if the cost report was not required
to be filed by Medicare.
(iii) HHSC will apply the state initiated rate reduction
prospectively beginning on the first day of the month following forty-five
(45) days after the date of the Final Base Rate Notification letter.
The final base rate is adjusted in accordance with paragraph (4) of
this subsection to determine the effective rate.
(iv) HHSC will not increase the effective rate for
an FQHC based on the outcome of a state-initiated cost report audit.
It is the responsibility of the FQHC to request HHSC to adjust the
effective rate if the FQHC can show that it is operating in an efficient
manner as defined in paragraph (7)(B) of this subsection, or can show
a change in scope as defined in paragraph (7)(A) of this subsection.
(v) For PPS the state initiated reviews is not applicable,
as described in subsection (a)(2) of this section.
(E) Final Base Rate Notification Letter. HHSC will
provide to an FQHC written notification of any determined final base
rate forty-five (45) days prior to implementation of the final base
rate. The effective date of the final base rate is determined by the
applicable FQHC Rate Determination Process described in subparagraph
(A) - (D) of this paragraph.
(F) Request for Review of Final Base Rate. The FQHC
may submit a written request for review of the final base rate within
30 days of the date of the Final Base Rate Notification Letter in
the circumstances described in clauses (i) - (iii) of this subparagraph.
(i) The FQHC believes that HHSC made a mathematical
error or data entry error in calculating the FQHC's reasonable cost.
The request for review must include the supporting documentation of
the perceived mathematical error or data entry error in calculating
the final base rate. HHSC will evaluate the request for review and
the merit of the supporting documentation. If HHSC determines the
request for review merits a change in the final base rate, HHSC will
adjust the final base rate to the effective date of the Final Base
Rate Notification Letter.
(ii) The FQHC believes that the FQHC made an error
in reporting its cost or data in the Texas Medicaid Supplemental Worksheets
described in paragraph (8)(A) of this subsection that would result
in a different calculation of the FQHC's reasonable cost. The request
for review must include the corrected Texas Medicaid Supplemental
Worksheets and supporting documentation of the correction of error
in reporting of cost or data. If HHSC determines the request for review
merits a change in the final base rate, HHSC may adjust the final
base rate to the effective date of the Final Base Rate Notification
Letter.
(iii) The FQHC believes that the FQHC made an error
in reporting its cost or data in the Final Audited Medicare Cost Report
described in paragraph (8)(B) of this subsection that would result
in a different calculation of the FQHC's reasonable cost. The request
for review must include the correspondence submitted to the Medicare
fiscal intermediary to amend the Medicare cost report. HHSC will consider
the request for review upon receipt of the provider amended Final
Audited Medicare Cost Report and supporting documentation of the correction
of error in reporting of cost or data. If HHSC determines the request
for review merits a change in the final base rate, HHSC may adjust
the final base rate to the effective date of the Final Base Rate Notification
Letter.
(iv) HHSC will send the FQHC written notification of
the results of its request for review.
(v) If the FQHC disagrees with the results of the review
in clause (iv) of this subparagraph, the FQHC may formally appeal
in accordance with §§357.481 - 357.490 of this title (relating
to Hearings Under the Administrative Procedure Act).
(11) In the event that the amount paid to an FQHC by
a managed care organization (MCO) or dental managed care organization
(DMO) is less than the amount the FQHC would receive under PPS or
APPS, whichever is applicable, the state will ensure the FQHC is reimbursed
the difference on at least a quarterly basis. The state's supplemental
payment obligation will be determined by subtracting the baseline
payment under the contract for services being provided from the effective
PPS or APPS rate without regard to the effects of financial incentives
that are linked to utilization outcomes, reductions in patient costs,
or bonuses.
(12) A visit is a face-to-face, telemedicine, or telehealth
encounter between an FQHC patient and a physician, physician assistant,
nurse practitioner, certified nurse-midwife, visiting nurse, a qualified
clinical psychologist, clinical social worker, other health professional
for mental health services, dentist, dental hygienist, or an optometrist.
Encounters with more than one health professional and multiple encounters
with the same health professional that take place on the same day
and at a single location constitute a single visit, except where one
of the following conditions exist:
(A) after the first encounter, the patient suffers
illness or injury requiring additional diagnosis or treatment; or
(B) the FQHC patient has a medical visit and an "other"
health visit, as defined in paragraph (13) of this subsection.
(13) A medical visit is a face-to-face, telemedicine,
or telehealth encounter between an FQHC patient and a physician, physician
assistant, nurse practitioner, certified nurse midwife, or visiting
nurse. An "other" health visit includes, but is not limited to, a
face-to-face, telemedicine, or telehealth encounter between an FQHC
patient and a qualified clinical psychologist, clinical social worker,
other health professional for mental health services, a dentist, a
dental hygienist, an optometrist, or a Texas Health Steps Medical
Screen.
(c) Payment dispute.
(1) An FQHC that believes an MCO or DMO has improperly
denied a claim for payment or has provided insufficient reimbursement
may appeal to the MCO or DMO. The MCO or DMO must address provider
appeals as required by Texas Government Code §533.005(a)(15)
and (19) and its contractual obligations with HHSC.
(2) If the MCO or DMO is not able to resolve the appeal,
the FQHC may submit a complaint to HHSC for review. If HHSC finds
the MCO or DMO has not correctly reimbursed the FQHC in accordance
with contractual obligations, HHSC may require the MCO or DMO to reimburse
the FQHC and assess remedies against the MCO or DMO in accordance
with HHSC's contract with the MCO or DMO.
(3) The state will ensure the FQHC is paid the full
PPS or APPS encounter rate for all valid claims.
(4) This subsection applies to claims for services
provided by an FQHC on an in-network or out-of-network basis.
|
| Source Note: The provisions of this §355.8261 adopted to be effective August 1, 1990, 15 TexReg 4120; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 1997, as published in the Texas Register December 11, 1998, 23 TexReg 12660; amended to be effective May 17, 2001, 26 TexReg 3481; amended to be effective October 13, 2002, 27 TexReg 9310; amended to be effective August 31, 2010, 35 TexReg 7044; amended to be effective January 26, 2011, 36 TexReg 233; amended to be effective September1, 2017, 42 TexReg 4283; amended to be effective February 28, 2021, 46 TexReg 1233 |
