| (a) HHSC pays a service provider agency for independent
living skills training, day habilitation, employment assistance, supported
employment, and behavioral support in accordance with the fee-for-service
rate for the specific service, which can be found on the HHSC website.
(b) To be paid for the provision of a service, the
service provider agency must submit a service claim that meets the
requirements in 40 TAC §49.311 (relating to Claims Payment) and
the IDD Habilitative Specialized Services Billing Guidelines.
(c) If a designated resident's IHSS are suspended or
terminated, the service provider agency must not submit a claim for
services provided during the period of the designated resident's suspension
or after the termination, except that the service provider agency
may submit a claim for the first day of the designated resident's
suspension or termination.
(d) HHSC does not pay the service provider agency for
a service if:
(1) the service is provided for a designated resident
when there is not a signed, dated, and authorized plan of care for
the designated resident; or
(2) the designated resident is ineligible for Medicaid
benefits at the time the service is provided.
(e) HHSC recoups any payments made to the service provider
agency for a service, if:
(1) the service is not provided in accordance with:
(A) a signed, dated, and authorized plan of care meeting
the requirements set forth in §368.301 of this chapter (relating
to Plan of Care);
(B) the designated resident's HSP;
(C) the designated resident's implementation plan;
or
(D) the IDD Habilitative Specialized Services Billing
Guidelines;
(2) the service is not documented in accordance with
Texas Medicaid Provider's Procedures Manual found on the TMHP website
and the IDD Habilitative Specialized Services Billing Guidelines;
(3) the claim for the service does not meet the requirements
in 40 TAC §49.311 or the IDD Habilitative Specialized Services
Billing Guidelines;
(4) HHSC determines that the service would have been
paid for by another source if the service provider agency had submitted
to the other source a proper, complete, and timely request for payment
for the service;
(5) the payment was for employment assistance or supported
employment and the service provider agency does not ensure or maintain
documentation in the designed resident's record that the service is
not available for the designated resident through a program funded
by the Rehabilitation Act of 1973;
(6) the service is provided by an individual service
provider who does not meet the qualifications to provide the service
as described in §368.406 of this chapter (relating to Provider
Qualifications) and the IDD Habilitative Specialized Services Billing
Guidelines; or
(7) the service is not provided.
(f) The service provider agency must refund to HHSC
any overpayment made to the service provider agency within 60 days
after the service provider agency's discovery of the overpayment.
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