| (a) Purpose. The Medicaid Recovery Audit Contractor
(RAC) Program is established under §1902(a)(42)(B) of the Social
Security Act (42 U.S.C. 1396a (a)(42)(B)) to review and identify underpayments
and overpayments, and to recoup overpayments for items or services
defined under the Medicaid State Plan or a waiver of the Medicaid
State Plan.
(b) Definitions. The following words and terms, when
used in this section, have the following meanings unless the context
clearly indicates otherwise:
(1) HHSC--The Texas Health and Human Services Commission,
the state Medicaid agency.
(2) HHS agency--One of the following health and human
services agencies:
(A) Department of Aging and Disability Services (DADS).
(B) Department of Assistive and Rehabilitative Services
(DARS).
(C) Department of Family and Protective Services (DFPS).
(D) Department of State Health Services (DSHS).
(3) Improper payment--An overpayment or an underpayment.
(4) Overpayment--An amount paid by HHSC or an HHS agency
to a provider that is in excess of the amount that is allowable for
services furnished under §1902 of the Social Security Act and
its implementing regulations and policies, as defined by the Centers
for Medicare & Medicaid Services (CMS), and that is required to
be refunded under §1903 of the Social Security Act.
(5) Recovery audit contractor (RAC)--An eligible company
or consultant contracted with HHSC to perform recovery audit services.
(6) Underpayment--An amount paid by HHSC or an HHS
agency to a provider at a lesser amount due and payable for items
or services furnished under §1902 of the Social Security Act
and its implementing regulations and policies, as defined by CMS.
(c) Scope of audits.
(1) A RAC will review Medicaid claims submitted to
HHSC by Medicaid providers for which payment has been made for any
item or service defined under the Medicaid State Plan or a waiver
of the Medicaid State Plan.
(2) The RAC will analyze Medicaid paid claims data
to determine if services were provided based on federal and state
policies and procedures in effect on the adjudication date for the
claim date of service. The analysis includes review of medical documentation
to determine if services were medically necessary.
(3) In conducting its audit review, the RAC will exclude
claims reviewed or under review by the HHSC Office of Inspector General
(OIG), or associated with any other audit already underway or completed,
including other federal and state audits or reviews.
(4) The RAC will make referrals of suspected fraud
and/or abuse, as defined in 42 CFR §455.2, to HHSC OIG. Any enforcement
action by HHSC OIG will be conducted under Chapter 371, Subchapter
G, of this title (relating to Legal Action Relating to Providers of
Medical Assistance).
(d) Audit procedures.
(1) A RAC will provide notification in writing to providers
of:
(A) audit policies and procedures;
(B) requests for medical documentation for selected
claims;
(C) results of the audit review (underpayment, overpayment,
or no findings), unless fraud is suspected; and
(D) the dispute resolution and appeals process.
(2) The RAC will accept medical documentation from
providers via mail; electronic submission on CD, DVD, or other method
of electronic submission allowed by the RAC; or by fax. All transmissions
of documentation must be protected in such a manner to comply with
the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
and in a manner that is safe and secure.
(3) To identify improper payments, the RAC will review
medical charts and documentation including:
(A) duplicate payments;
(B) pricing errors;
(C) payments for services not provided;
(D) payments for non-covered services; or
(E) any other errors resulting in improper payments.
(4) HHSC will recoup identified overpayments from providers
and will refund identified underpayments to providers as a result
of the audit review.
(e) Notice. A RAC will provide written notification
to providers of the following during the course of the audit:
(1) audit review information (for example, audit name,
audit description);
(2) potential improper payment;
(3) detailed reason for the potential improper payment;
and
(4) appeal rights.
(f) Provider appeals. A provider has a right to appeal
any adverse RAC determination using the following processes, as applicable:
(1) HHSC paid claims. For Medicaid claims processed
and paid through the Texas Medicaid claims administrator on behalf
of HHSC, the appeal will be processed through the Medicaid Program
Appeals Procedures process under §354.2217 of this chapter (relating
to Provider Appeals and Reviews).
(2) HHS agency paid claims. For Medicaid claims adjudicated
by the Texas Medicaid claims administrator and paid by an HHS agency,
or adjudicated and paid by an HHS agency, the appeals process for
that HHS agency will be followed.
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