Current through Reg. 49, No. 36; September 6, 2024
Section 52.121 - Claims Payment(a) HHSC pays a contractor for a claim for services that meets the requirements described in subsection (b) of this section.(b) A contractor must ensure a claim for services is: (1) for a service that has been provided by a contractor;(3) complete and accurate;(4) submitted within 12 months after one of the following, whichever is later: (A) the last day of the month in which the service was provided, the adaptive aid or medical supply delivered, or the minor home modification completed; or(B) the date the individual's eligibility for the service was determined;(5) for a type and amount of service that is authorized by HHSC;(6) for a service provided to an individual who is eligible for the service;(7) except as provided in HHSC rules governing services provided under the contract, for a service provided to an individual whose authorization for services has not been suspended or terminated by HHSC;(8) for a service provided during a time period authorized by HHSC;(9) for a service provided during the term of, and in accordance with, the contract, this subchapter, and HHSC rules governing services provided under the contract;(10) supported by records required by the contract and HHSC rules governing services provided under the contract;(11) for a service provided by a qualified service provider in accordance with HHSC rules governing services provided under the contract;(12) for a service ordered by a qualified practitioner, if required by the contract or HHSC rules governing services provided under the contract;(13) submitted in accordance with procedures required by HHSC rules governing services provided under the contract and by the claims administrator; and(14) not for a service that a source other than HHSC would have paid for if the contractor had submitted a proper, complete, and timely request for payment to the other source.(c) As used in subsection (b)(11) and (12) of this section, the terms "qualified service provider" and "qualified practitioner" do not include a person whose health-related license has been suspended or revoked or who has been excluded from participation in a program administered under Title V, XVIII, XIX, or XX of the Social Security Act.(d) HHSC denies a claim for services that does not meet the requirements in subsection (b) of this section and HHSC rules governing services provided under the contract. If HHSC denies a claim for services, a contractor may request and receive an administrative hearing.(e) If a contractor or HHSC determines that the contractor received payment for a claim for services that does not meet the requirements in subsection (b) of this section and HHSC rules governing services provided under the contract: (1) the contractor may submit a corrected claim for services to allow HHSC to adjust amounts paid to a contractor, even if it is after the 12-month period described in subsection (b)(4) of this section; or(2) HHSC recoups funds paid to the contractor in accordance with § 49.533 of this chapter (relating to Recoupment).(f) If a claim for services is denied by HHSC , the contractor that submitted the claim may submit a corrected claim within the 12-month period described in subsection (b)(4) of this section.(g) HHSC may adjust amounts paid to a contractor after the 12-month period described in subsection (b)(4) of this section.26 Tex. Admin. Code § 52.121
Transferred from 40 TAC § 49.311 Texas Register, Volume 49, Number 13, March 29, 2024, TexReg 2091, eff. 4/29/2024