§9.573: Reimbursement

(a) Program provider reimbursement.

(1) DADS pays the program provider for service components as follows:

(A) Community support, nursing, respite, day habilitation, employment assistance, supported employment, behavioral support, and specialized therapies are paid for in accordance with the reimbursement rate for the specific service component.

(B) Adaptive aids, minor home modifications, and dental treatment are paid for based on the actual cost of the item or service and an allowed requisition fee.

(2) The program provider must accept DADS' payment for a service component as payment in full for the service component.

(3) If the program provider disagrees with the enrollment date of an individual as determined by DADS, the program provider must notify DADS in writing of its disagreement, including the reasons for the disagreement, within 180 days after the end of the month in which the program provider receives the enrollment approval letter. DADS reviews the information submitted by the program provider and notifies the program provider, the MRA, and the individual or LAR of its determination regarding the individual's enrollment date.

(4) The program provider must prepare and submit claims for service components in accordance with this subchapter, the TxHmL Provider Agreement, and the TxHmL Service Definitions and Billing Guidelines.

(5) The program provider must submit an initial claim for a service component as follows:

(A) Community support, nursing, respite, day habilitation, employment assistance, supported employment, behavioral support, and specialized therapies must be electronically transmitted to DADS via the automated enrollment and billing system.

(B) Adaptive aids, minor home modifications, and dental treatment must be submitted in writing to DADS for entry into the automated enrollment and billing system.

(6) The program provider must submit a claim for a service component to DADS by the latest of the following dates:

(A) within 95 calendar days after the end of the month in which the service component was provided;

(B) within 45 calendar days after the date of the enrollment approval letter issued by DADS; or

(C) within 95 calendar days after the end of the month in which the program provider obtains from the MRA a dated response from a non-TxHmL Program source for which the individual may be eligible, refusing or denying a correctly submitted request for payment for or provision of the service component.

(7) If an individual is temporarily or permanently discharged from the TxHmL Program, the program provider may submit a claim for a service component provided on the day of the individual's discharge.

(8) If DADS rejects a claim for adaptive aids, minor home modifications, or dental treatment, the program provider may submit a corrected claim to DADS. The corrected claim must be received by DADS within 180 days after the end of the month in which the service component was provided or within 45 days after the date of the notification of the rejected claim, whichever is later.

(9) If the program provider submits a claim for an adaptive aid or dental treatment, the program provider must submit documentation obtained from the MRA demonstrating that sources of payment other than the TxHmL Program for which the individual may be eligible, including Medicare, Medicaid (such as Texas Health Steps and Home Health), a state rehabilitation agency, the public school system, and private insurance, denied a request for payment. Such documentation must include evidence that a proper, complete, and timely request for payment or provision of the service component was made to the other payment source and that payment or provision of the service was denied.

(10) If the program provider submits a claim for an adaptive aid that costs $500 or more or for a minor home modification that costs $1,000 or more, the program provider must submit an individualized assessment conducted by a professional qualified to assess whether the aid or modification is necessary and appropriate to address the individual's needs and other documentation in accordance with DADS instructions.

(11) DADS does not pay the program provider for a service component or recoups any payments made to the program provider for a service component if:

(A) the individual receiving the service component was, at the time the service component was provided, ineligible for the TxHmL Program or Medicaid benefits, or was an inpatient of a hospital, nursing facility, or intermediate care facility for persons with mental retardation;

(B) the service component was not included on the signed and dated IPC of the individual in effect at the time the service component was provided;

(C) the service component provided did not meet the service definition as described in §9.555 of this subchapter (relating to Definitions of TxHmL Program Service Components) or was not provided in accordance with the TxHmL Service Definitions and Billing Guidelines;

(D) the service component was not documented in accordance with the TxHmL Service Definitions and Billing Guidelines;

(E) the claim for the service component was not prepared and submitted in accordance with the TxHmL Service Definitions and Billing Guidelines;

(F) documentation as required by paragraph (10) of this subsection was not submitted by the program provider;

(G) DADS determines that the service component would have been paid for by a source other than the TxHmL Program;

(H) the service component was provided by a service provider who did not meet the qualifications to provide the service component as described in the TxHmL Service Definitions and Billing Guidelines;

(I) the service component was not provided in accordance with a signed and dated IPC meeting the requirements set forth in §9.558 of this subchapter (relating to Individual Plan of Care (IPC);

(J) the service component was not provided in accordance with the PDP;

(K) the service component was provided before the individual's enrollment date into the TxHmL Program; or

(L) the service component was not provided.

(12) The program provider must refund to DADS any overpayment made to the program provider within 60 days after the program provider's discovery of the overpayment or receipt of a notice of such discovery from DADS, whichever is earlier.

(13) Payments by DADS to a program provider are not withheld in the event the MRA erroneously fails to submit a renewal of an enrolled individual's LOC or IPC and the program provider continues to provide services in accordance with the most recent IPC as approved by DADS.

(b) CDSA reimbursement. For an individual participating in CDS, DADS pays the CDSA for the service components listed in §9.554(g) of this subchapter (relating to Description of the TxHmL Program) that are provided through CDS, in accordance with the reimbursement rate established by HHSC.

(c) Billing and payment reviews.

(1) DADS conducts billing and payment reviews to monitor a program provider's compliance with this subchapter and the TxHmL Program Service Definitions and Billing Guidelines. DADS conducts such reviews in accordance with the TxHmL Billing and Payment Review Protocol set forth in the TxHmL Program Service Definitions and Billing Guidelines. As a result of a billing and payment review, DADS 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 DADS instructions, a corrective action plan that improves the program provider's billing practices.

(2) A corrective action plan required by DADS in accordance with paragraph (1)(B) of this subsection 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 DADS within 30 calendar days after the date the program provider is notified the corrective action plan is required; and

(C) be approved by DADS before implementation.

(3) Within 30 calendar days after the corrective action plan is received by DADS, DADS notifies the program provider if the corrective action plan is approved or if changes to the plan are required.

(4) If DADS requires a program provider to develop and submit a corrective action plan in accordance with paragraph (1)(B) of this subsection and the program provider requests an administrative hearing for the recoupment in accordance with §9.575 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. DADS 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.

(5) If the program provider does not submit the corrective action plan or complete the required corrective action within the time frames described in paragraph (2) of this subsection, DADS may impose a vendor hold on payments due to the program provider under the program provider agreement until the program provider takes the corrective action.

(6) If the program provider does not submit the corrective action plan or complete the required corrective action within 30 calendar days after the date a vendor hold is imposed in accordance with paragraph (5) of this subsection, DADS may terminate the program provider agreement.

Comments

Source Note: The provisions of this §9.573 adopted to be effective January 5, 2003, 27 TexReg 12254; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective March 1, 2007, 32 TexReg 544; amended to be effective June 1, 2008, 33 TexReg 4340