1 Tex. Admin. Code § 354.2321 - Provider Billing and Recovery From Third Party Resources
(a) Providers must
make a good faith effort to determine whether a recipient is or may be insured
by a third party resource at the time services are provided, by making a
reasonable attempt to verify with the recipient either orally or in.
(b) If a third party resource is identified,
providers are required to bill the third party resource before submitting a
claim for payment to HHSC under the provisions of §
354.1003 of this chapter (relating
to Time Limits for Submitted Claims) unless otherwise directed by
HHSC.
(c) Providers who identify a
third party resource, within 12 months from the date of service, and wish to
submit a claim for payment to a third party resource after a claim for payment
has been submitted and paid by HHSC, must refund any amounts paid by Medicaid
prior to submitting a claim for payment to the third party resource.
(d) Providers are limited to the Medicaid
payable amount and the provider is required to accept the amount paid by HHSC
as payment in full if:
(1) a claim for payment
is submitted to and paid by HHSC; and
(2) the provider failed to inform HHSC at the
time the claim was filed, or any time thereafter, that a third party resource
was also billed for the same service.
(e) Payments made by a third party resource
to a provider who is limited to the Medicaid payable amount under subsection
(d) of this section must be forwarded to HHSC for distribution as follows:
(1) for fee-for-service (FFS), according to
the provisions of §
354.2334 of this subchapter
(relating to Notices and Payments); or
(2) for Medicaid managed care, according to
provisions as outlined in the provider's contract with an MCO.
(f) If the amount paid by a third
party resource is less than the amount payable for the service by Medicaid,
HHSC may be billed for the difference between the amount paid by the third
party resource and the Medicaid payable amount, if a claim was timely filed
with HHSC under the provisions of §
354.1003 of this chapter.
(g) Any provider who accepts Medicaid payment
as payment in full for health care items or services and retains any amount in
excess of the Medicaid payable amount from a third party resource and conceals
or fails to account to HHSC for the third party amount, resulting in excessive
or duplicate payment for the same health care items or services, may be
referred for investigation and prosecution for violations of state or federal
Medicaid or false claims laws, or both.
(h) Providers are prohibited from submitting
a bill, or other written demand for payment or collection of debt for any
Medicaid-covered service from an individual who the provider knows or should
know is a Medicaid eligible recipient or from the representative of a
recipient, regardless of whether a claim for payment for the service is
submitted to HHSC. This section does not prohibit a provider from submitting
reasonable inquiries or requests for information to a recipient, or
representative of a recipient to assist the provider in identifying a third
party resource. However, any inquiry which would lead a reasonable person to
believe that the provider was making a demand for payment, or attempting to
collect an unpaid debt, will bring the provider within the limitations and
prohibitions as follows.
(1) If a provider
attempts to recover any amount from a recipient for any Medicaid-covered
service, HHSC may provide for a reduction of an amount otherwise payable to the
provider in addition to referring the provider for investigation and
prosecution for violations of state or federal Medicaid or false claims laws,
or both.
(2) The amount of the
reduction may be up to three times the amount the provider sought in excess of
the Medicaid payable amount.
(i) Providers are prohibited from refusing to
provide health care items or services to a Medicaid recipient because the
recipient has a third party resource that may potentially be liable for payment
of health care items or services.
(j) Eventual recovery, repayment or
recoupment of money by HHSC or the recipient will not release or preclude
referral by HHSC for investigation, prosecution or liability under any civil or
criminal law which would otherwise apply to the unlawful conduct.
(k) HHSC will not accept any claim for
payment under this section submitted after 18 months from the date of service,
regardless of whether an informational claim has been timely filed.
(l) A payment made by a third party resource
to HHSC or a provider on a claim for payment of a health care item or service
provided to a Medicaid recipient is final on the date that is two years after
the third party payment was made. After a claim is final, the claim is subject
to adjustment only if an action for recovery of an overpayment was commenced
under subsection (b) of this section before the date the claim became final and
the recovery is agreed to by HHSC under subsection (c) of this
section.
(m) If a third party
resource determines that it overpaid a claim for payment, the third party
resource may seek to recover all or part of the overpayment by filing a notice
of its intent to seek recovery with HHSC in writing before the date the payment
is final. The notice must specify all of the following:
(1) the full name of the Medicaid recipient
who received the health care item or service that is the subject of the
claim;
(2) the date on which the
health care item or service was provided;
(3) the amount allegedly overpaid and the
amount the third party resource seeks to recover;
(4) the claim number and any other number
HHSC has assigned to the claim;
(5)
the third party resource's rationale for seeking recovery;
(6) the date the third party resource made
the payment and the method of payment used;
(7) if payment was made by check, the check
number; and
(8) whether the third
party resource would prefer to receive payment from HHSC, or prefer HHSC to
offset the amount from a future payment.
Notes
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