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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 §371.201Case Selection Process

(a) The Texas Health and Human Services Commission (Commission) selects Texas Medical Review Program (TMRP) cases for review by a statistically valid random sampling methodology and/or focused case selection. Cases will consist of paid inpatient claims for diagnostic related groups (DRGs), which may include:

  (1) Readmissions up to 30 days;

  (2) Ambulatory surgical procedures billed on inpatient claims;

  (3) Questionable admissions or claims coding identified by other entities;

  (4) Admissions identified through the Commission's quality review program as potential quality of care concerns;

  (5) DRG payments made to freestanding rehabilitation facilities;

  (6) Day or cost outlier payments; or

  (7) Any other DRG or claims submission errors.

(b) The Commission selects Tax Equity and Fiscal Responsibility Act and facility specific per diem methodology cases for review by a statistically valid random sampling methodology and/or focused case selection. Cases will consist of paid inpatient claims for admissions to children's hospitals and freestanding psychiatric facilities.


Source Note: The provisions of this §371.201 adopted to be effective January 1, 1993, 17 TexReg 8457; transferred effective September 1, 1993, as published in the Texas Register January 28, 1994, 19 TexReg 589; amended to be effective July 27, 1994, 19 TexReg 5493; 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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