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TITLE 1ADMINISTRATION
PART 15TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 371MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY
SUBCHAPTER CUTILIZATION REVIEW
RULE §371.200Inpatient Hospital Utilization Review Program

(a) The Texas Medical Review Program (TMRP) is the inpatient hospital utilization review process used by the Texas Health and Human Services Commission (Commission) for hospitals reimbursed under the Commission's prospective payment system. The Commission conducts the TMRP in accordance with:

  (1) applicable federal regulations at 42 Code of Federal Regulations Part 456, Subparts A, B, and C, which require the Commission to operate a utilization review program that controls the utilization of inpatient hospital services and assesses the appropriateness and quality of those services; and

  (2) an approved waiver under the Social Security Act, §1903(i)(4), as it relates to the use of Title XVIII utilization review procedures for Title XIX patients in acute care general hospitals other than hospitals reimbursed under the Tax Equity and Fiscal Responsibility Act (TEFRA) reimbursement principles.

(b) The TEFRA review process relates directly to hospitals reimbursed under the TEFRA reimbursement principles and facility specific per diem methodology.


Source Note: The provisions of this §371.200 adopted to be effective June 14, 1989, 14 TexReg 2624; transferred effective September 1, 1993, as published in the Texas Register January 28, 1994, 19 TexReg 589; amended to be effective November 22, 1995, 20 TexReg 9274; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000, 25 TexReg 1308; amended to be effective March 30, 2003, 28 TexReg 2481; amended to be effective January 1, 2014, 38 TexReg 9479

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