| (ii) a detailed, written statement concerning the relationship
of the computer problem to delayed claims submission; and
(iii) the reason alternative billing procedures were
not initiated after the problem(s) became known.
(5) Other exceptions to claims receipt or correction
and resubmission deadlines. The manager of the department unit having
responsibility for oversight of the program or his or her designee(s)
will consider a provider's request for an exception to claims receipt
or correction and resubmission deadlines due to delays caused by entities
other than the provider and the program under the following circumstances:
(A) all claims that are to be considered for the same
exception must accompany the request;
(B) only the claim(s) that are attached to the request
will be considered;
(C) the exception request has been received by the
program within 18 months from the date of service; and
(D) the exception request includes an affidavit or
statement from a representative of an original payer, a third party
payer, or a person who has personal knowledge of the facts, stating
the exception being requested, documenting the cause for the delay,
and providing verification that the delay was caused by another entity
and not the neglect, indifference, or lack of diligence of the provider
or the provider's employee(s) or agent(s).
(6) Program fees. The program establishes fees and
payment methodologies for covered medical, dental, and other services
based upon appropriated funds. All fees are subject to reductions
or limitations authorized by §38.16(b)(2)(E) of this title (relating
to Procedures to Address Program Budget Alignment).
(7) Required documentation. The program may require
documentation of the delivery of goods and services from the provider.
(8) Overpayments.
(A) Overpayments are payments made by the program due
to the following:
(i) duplicate billings;
(ii) services paid by public or private insurance or
other resources;
(iii) payments made for services not delivered;
(iv) services disallowed by the CSHCN Services Program;
and
(v) subrogation.
(B) Overpayments made to providers must be reimbursed
to the department by lump sum payment or, at the department's discretion,
offset against current payments due to the provider for services to
other clients. The department also shall require reimbursement of
overpayments from any person or persons who have a legal obligation
to support the client and have received payments from a payer of other
benefits. Providers, clients, and person(s) responsible for clients
may appeal proposed recoupment of overpayments by the department according
to §38.13 of this title.
|
| Source Note: The provisions of this §351.10 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective October 11, 2001, 26 TexReg 7870; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective January 1, 2004, 28 TexReg 11268; amended to be effective August 1, 2004, 29 TexReg 7103; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982 |
