Texas Statutes
Subchapter C. Medicaid and Other Health and Human Services Fraud, Abuse, or Overcharges
Section 531.1135. Managed Care Organizations: Process to Recoup Certain Overpayments

Sec. 531.1135. MANAGED CARE ORGANIZATIONS: PROCESS TO RECOUP CERTAIN OVERPAYMENTS. (a) The executive commissioner shall adopt rules that standardize the process by which a managed care organization collects alleged overpayments that are made to a health care provider and discovered through an audit or investigation conducted by the organization secondary to missing electronic visit verification information. In adopting rules under this section, the executive commissioner shall require that the managed care organization:
(1) provide written notice of the organization's intent to recoup overpayments not later than the 30th day after the date an audit is complete; and
(2) limit the duration of audits to 24 months.
(b) The executive commissioner shall require that the notice required under this section inform the provider:
(1) of the specific claims and electronic visit verification transactions that are the basis of the overpayment;
(2) of the process the provider should use to communicate with the managed care organization to provide information about the electronic visit verification transactions;
(3) of the provider's option to seek an informal resolution of the alleged overpayment;
(4) of the process to appeal the determination that an overpayment was made; and
(5) if the provider intends to respond to the notice, that the provider must respond not later than the 30th day after the date the provider receives the notice.
(c) Notwithstanding any other law, a managed care organization may not attempt to recover an overpayment described by Subsection (a) until the provider has exhausted all rights to an appeal.
Added by Acts 2019, 86th Leg., R.S., Ch. 667 (S.B. 1991), Sec. 3, eff. September 1, 2019.

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