| (I) supported home living, if the supported home living,
was not provided in accordance with a transportation plan and §263.5(a)(18)
of this chapter (relating to Description of HCS Program Services);
or
(J) CFC PAS/HAB, in-home day habilitation provided
to an individual with a residential type of "own/family home,"
or in-home respite, if the CFC PAS/HAB, in-home day habilitation,
or in-home respite, 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 calendar 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 section,
if HHSC approves an LOC requested in accordance with §263.105(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 a program provider submitted
an ID/RC Assessment more than 180 calendar days after the expiration
date of the previous ID/RC Assessment, because of circumstances beyond
the program provider's control, HHSC may pay the program provider
for a period of more than 180 calendar days after the date the individual's
previous ID/RC Assessment expired.
(9) HHSC conducts provider fiscal compliance reviews
to determine whether a program provider is in compliance with:
(A) this chapter;
(B) the HCS Program Billing Requirements;
(C) the CFC Billing Requirements for HCS and TxHmL
Program Providers;
(D) 40 TAC §§49.301-49.313; and
(E) the program provider's Community Services Contract-Provider
Agreement.
(10) HHSC conducts provider fiscal compliance reviews
in accordance with the Provider Fiscal Compliance Review Protocol
set forth in the HCS 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.
(11) A corrective action plan required by HHSC in accordance
with paragraph (10)(B) of this section 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.
(12) 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.
(13) If HHSC requires a program provider to develop
and submit a corrective action plan in accordance with paragraph (10)(B)
of this section and the program provider requests an administrative
hearing for the recoupment in accordance with §263.802 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.
(14) If a program provider does not submit a corrective
action plan or complete a required corrective action within the time
frames described in paragraph (11) of this section, HHSC may impose
a vendor hold on payments due to the program provider until the program
provider takes the corrective action.
(15) 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
(14) of this section, HHSC may terminate the contract.
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