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RULE §353.504Review of Managed Care Organization's Records

(a) Immediately upon request, the Health and Human Services Commission, Office of Inspector General (HHSC-OIG), Office of the Attorney General-Medicaid Fraud Control Unit (OAG-MFCU) and OAG, Office of the Attorney General-Civil Medicaid Fraud Division (OAG-CMFD), and the United States Health and Human Services, Office of Inspector General (HHS-OIG) may review the records of a managed care organization (MCO) to determine compliance with this subchapter.

(b) Upon receipt of a record review request from any state or federal agency authorized to conduct compliance, regulatory, or program integrity functions, an MCO must:

  (1) At no charge to the entities identified in subsection (a) of this section, provide the records requested by a properly identified agent of any state or federal agency authorized to conduct compliance, regulatory, or program integrity functions on the provider, person, MCO, or the services rendered by the provider or person within 24 hours of the request.

  (2) An exception to the 24 hours stated in paragraph (1) of this subsection may be made when the OIG or another state or federal agency representative reasonably believes that the requested records are about to be altered or destroyed or that the request may be completed at the time of the request and/or in less than 24 hours.

(c) The request for record review may include, but is not limited to:

  (1) clinical medical or dental patient records;

  (2) other records pertaining to the patient;

  (3) any other records of services provided to Medicaid or other health and human services program recipients and payments made for those services;

  (4) documents related to diagnosis, treatment, service, lab results, charting;

  (5) billing records, invoices, documentation of delivery items, equipment, or supplies;

  (6) radiographs and study models related to orthodontia services;

  (7) business and accounting records with backup support documentation;

  (8) statistical documentation;

  (9) computer records and data; and

  (10) contracts with providers and subcontractors.

(d) Failure to produce the records or make the records available for the purpose of reviewing, examining, and securing custody of the records may result in HHSC imposing contractual remedies or HHSC-OIG imposing sanctions against the MCO as described in Chapter 371, Subchapter G of this title (relating to Legal Action Relating to Providers of Medical Assistance), or both remedies and sanctions.

Source Note: The provisions of this §353.504 adopted to be effective August 8, 2004, 29 TexReg 7301; amended to be effective March 1, 2012, 37 TexReg 1291

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