Texas Register, Volume 28, Number 14, Pages 2821-2988, April 4, 2003 Page: 2,862
2821-2988 p. ; 28 cm.View a full description of this periodical.
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claims. Payment is denied if these [the] time limits [frames] are not
met. Time limits are as follows:
(1) THSteps [EPSDT] medical check-up provider [screen-
inhag] claims must be received by HHSC or its designee [the health in-
s ing agent] within 95 days from each date of service on the claim.
{(2) Claims for diagnostic and treatment services mast be
received by the health insuring agent within 95 days from each date of
service on the claims.]
(2) [{3)] If a service is billed to another insurance resource,
the claim must be received by HHSC or its designee within 95 days of
the claim disposition by the other resource.
(3) [(4)] If a service is billed to a third-party resource that
has not responded, the claim must be received by HHSC or its designee
[the health insuring agent] within 365 days [12 months] of the service
date; however, the claim must not be submitted to HHSC or its designee
[the health insuring agent] before 110 days after the third party has been
billed.
(b) All appeals of denied claims and requests for claims adjust-
ments must be received by HHSC or its designee [the health insuring
agent] within 180 days from the date of the last denial of and/or adjust-
ment to the original claim.
(c) Claims received by HHSC or its designee [the health insur-
ing agent] which are lacking the information necessary for processing
are listed on the R&S report with an EOB code requesting the miss-
ing information [denied as incomplete claims]. The resubmission of
the claim containing the necessary information must be received by
HHSC or its designee [the health insuring agent] within 180 days from
the date on the R&S to be considered for payment [last denial date].
33.140. Management of Complaints.
TDH will report all allegations of Medicaid fraud and other unlawful
activities to the appropriate authority for review of the allegations and
determination of the appropriate action as defined in TDH policy. TDH
will refer all complaints alleging quality of care issues to the appropri-
ate licensing or regulatory authority.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal author-
ity to adopt.
Filed with the Office of the Secretary of State on March 21, 2003.
TRD-200301859
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
25 TAC 33.139
(Editor's note: The text of the following section proposed for repeal
will not be published. The section may be examined in the offices of the
Texas Department of Health or in the Texas Register office, Room 245,
James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeal is proposed under the Human Resources Code,
32.021(c), which allows the department to establish rules
governing the Medicaid program; the Health and Safety Code,
12.001, which provides the Texas Board of Health (board)
with the authority to adopt rules for its procedures and the
performance of each duty imposed by law on the board,the department and the Commissioner of Health; and the
Government Code, 531.021, which provides the Health and
Human Services Commission with the authority to administer
the state's medical assistance program and are submitted by
the department under its agreement with the Health and Human
Services Commission to operate the Early and Periodic Screen-
ing, Diagnosis, and Treatment program as authorized under
Acts 1991, 72nd Legislature, First Called Session, Chapter 15,
1.07.
The proposed repeal affects the Human Resources Code, Chap-
ter 32.
33.139. Replacement of Hearing Aids.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal author-
ity to adopt.
Filed with the Office of the Secretary of State on March 21, 2003.
TRD-200301860
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
CHAPTER 33. EARLY AND PERIODIC
SCREENING, DIAGNOSIS, AND TREATMENT
The Texas Department of Health (department) proposes
amendments to 33.301-33.304, 33.334, 33.351-33.358,
new 33.305-33.311, 33.314-33.315, 33.317-33.320, 33.331,
and the repeal of 33.305-33.309, 33.312-33.318, and
33.331-33.333 concerning the Texas Health Steps dental
services.
Specifically, the proposed amendments to 33.301-33.304
cover definitions; oral evaluations and dental services; preven-
tive dental services, and therapeutic dental services. Proposed
new 33.305-33.311 covers orthodontic services limitations,
eligibility for orthodontic services, payment limitations for
orthodontic services, emergency dental services; allowable
services and limitations; eligibility for Texas Health Steps
dental services, and requirements for provider enrollment and
continuing participation. Proposed new 33.314-33.315 cover
charges to recipients and payment of claims. Proposed new
33.317-33.320 cover change to another provider; and stan-
dards of care. Proposed new 33.331 covers the purpose of the
dental utilization review process; the proposed amendment to
33.334 covers post-payment orthodontic review; the proposed
amendments to 33.351-33.352 cover types of department
utilization reviews and selection of dentists for department
utilization review. The proposed amendment to 33.353 adds
a requirement that the notice to providers of a utilization review
be in writing. The proposed amendments to 33.354-33.358
cover provider cooperation, disposition of department utilization
review results, recoupment of overpayments as a result of
department utilization review, administrative actions and/or
sanctions and referral for investigation of fraud or program
abuse.
Specifically, the proposed repeals of 33.331-33.333 cover or-
thodontic service limitations, eligibility for orthodontic services
and payment limitations for orthodontic services.28 TexReg 2862 April 4, 2003 Texas Register
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Texas. Secretary of State. Texas Register, Volume 28, Number 14, Pages 2821-2988, April 4, 2003, periodical, April 4, 2003; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth101027/m1/41/: accessed June 5, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.