| (a) HHSC assigns an applicant or re-enrolling provider
a screening level of "Limited," "Moderate," or "High" based on:
(1) the federal screening level for the type of provider
as provided by 42 CFR §424.518, if applicable;
(2) the federal screening level for the type of provider
as provided by 42 CFR §455.450; or
(3) HHSC's assessment of:
(A) the risk level for potential fraud, waste, or abuse
associated with the type of provider or the geographical area; or
(B) other factors as determined by HHSC, including:
(i) a change in business structure or organization;
(ii) past practices and circumstances; and
(iii) access to care in a geographical area.
(b) For a screening level of "Limited" or "Moderate"
assigned under subsection (a) of this section, HHSC may assign a higher
screening level based on provider, type of provider, or geographical
area. For the requirements outlined in subsection (c) of this section,
HHSC may rely on other validated screenings performed by Medicare,
as provided for by 42 C.F.R. §455.410.
(c) Requirements for screening levels.
(1) Limited.
(A) For a provider assigned a screening level of "Limited,"
HHSC:
(i) verifies that a provider meets any federal or state
requirements for that type of provider;
(ii) verifies licensure certifications, including licensure
certifications in Texas and any other state; and
(iii) conducts database checks pursuant to 42 CFR §455.436.
(B) A provider assigned a screening level of "Limited"
must submit a new enrollment application at least every five years,
unless HHSC determines a shorter enrollment period.
(2) Moderate.
(A) For a provider assigned a screening level of "Moderate,"
HHSC:
(i) performs the screening described in paragraph (1)(A)
of this subsection; and
(ii) performs at least one unscheduled and unannounced
pre- and post-enrollment site visit in accordance with 42 CFR §455.432.
(B) A provider assigned a screening level of "Moderate"
must submit a new enrollment application at least every five years,
unless HHSC determines a shorter enrollment period.
(3) High.
(A) For a provider assigned a screening level of "High,"
HHSC:
(i) performs the screening described in paragraph (2)(A)
of this subsection;
(ii) conducts a criminal background check; and
(iii) requires the submission of a set of fingerprints
if applicable under 42 CFR §455.434.
(B) A provider assigned a screening level of "High"
must submit a new enrollment application at least every three to five
years, unless:
(i) HHSC determines a shorter enrollment period; or
(ii) the provider meets the requirements of §371.1007
of this title (relating to Screening Levels).
(d) In addition to the screening requirements provided
under this section, additional screening may be performed under §371.1009
of this title (relating to Verifications Required for Each Screening
Level).
(e) A screening level assigned under subsection (a)(3)
of this section is within the sole discretion of HHSC and is not subject
to administrative review.
|
