Texas Register, Volume 28, Number 14, Pages 2821-2988, April 4, 2003 Page: 2,869
2821-2988 p. ; 28 cm.View a full description of this periodical.
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established principles of dental care. The TDH [department] shall ap-
ply review and screening criteria with flexibility appropriate to the cir-
cumstances of each case.
33.352. Selection of Dentists for TDH [Departmemt] Utilization Re-
view.
(a) An individual or group dental provider may be selected by
the TDH [department] for a utilization review as a result of:
(1)-(2) (No change.)
(3) information or complaints received by the TDH [de-
partment], except those alleging fraud or abuse or concerning the prac-
tice of dentistry as described in 33.319 [33.317] of this title (relating
to Management of Complaints).
(b) Providers suspected of program fraud or abuse shall [will]
not be subject to a utilization review by the TDH [department, but will
instead be referred to]. The TDH shall refer such providers to the OIE
for disposition.
(c) The division shall refer complaints [Gomplaints] regarding
the practice of dentistry [will be referred] to the SBDE.
33.353. Notification to Provider of TDH [Department] On-Site Uti-
lization Review.
(a) The TDH [department] shall give the provider at least 30
days written notice of the time and place of a utilization review, unless
such notice would jeopardize an active investigation.
(b)-(c) (No change.)
33.354. Provider Cooperation.
(a) The provider, the provider's associate(s) in a group prac-
tice, or the provider's office staff shall not contact, examine, or treat
recipients identified as part of the utilization review [(with the excep-
tion of emergency services as defined in #33~P05 of this title (relating to
Emergency Dental Services, or pn approval ofte vider' .request
by the department)] from the time the provider receives written notifi-
cation identifying the recipients to be reviewed until notified in writing
by the TDH [department] that normal contacts may be resumed. There
are two exceptions to this exclusion:
(1) for emergency services as defined in 33.308 of this
title (relating to Emergency Dental Services); or
(2) upon approval of the provider's request by the TDH.
(b)-(c) (No change.)
33.355. Disposition of TDH [Department] Utilization Review Re-
sults.
The results of utilization reviews, either automated or on-site, shall
be forwarded by the TDH or HHSC's designee [department or by its
claims processing contractor] to the OIE for evaluation and final dis-
position. Results of a review which reflects no deviation from review
standards shall [will] be forwarded [mailed] to the provider within 30
days of [ia timely manner upon] completion of the review.
33.356. Recoupment of Overpayments as a Result of TDH [Depart-
menit] Utilization Review.
If the results of a TDH [department] utilization review indicate
overpayment for services delivered or that payment was made for
services not delivered, recoupment is required. The appropriate
agency or agency designee shall [will] notify the provider in writing
of any overpayment identified and the method of recoupment to be
used. [A provider' s reeopment obligation may involve either or both
of the following:][(14-) the dollar amount of the discrepancies in the claims
reviewedj er}
[(2) a dollar amount calculated by applying the monetary
discrepancy rate found in the claims reviewed to all remaining claims
for the types of services sampled with dates of service during the period
under review.]
33.357. Administrative Actions and/or Sanctions.
Evaluation of a utilization review may result in one or more of the fol-
lowing administrative actions or sanctions by the appropriate agency
or the agency's designee:
(1)-(2) (No change.)
(3) recoupment of any overpayment identified according to
33.356 of this title (relating to Recoupment of Overpayments as a
Result of TDH [Department] Utilization Review);
(4)-(8) (No change.)
33.358. Referral for Investigation of Fraud or Program Abuse.
All allegation of Medicaid fraud and other unlawful activities will be
reported to the appropriate authority for review of the allegations and
determination of the appropriate action as defined in TDH policy. All
complaints alleging quality of care issues will be referred to the ap-
propriate licensing or regulatory authority. [Suspected eases of fraud
or abuse will be immediately referred to the 1 Department utiliza-
tion reviews will not be initiated on any provider suspected of fraud or
abuse.]
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 24, 2003.
TRD-200301894
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
SUBCHAPTER J. TEXAS HEALTH STEPS
MEDICAL CASE MANAGEMENT
25 TAC 33.501 - 33.506
(Editor's note: The text of the following sections proposed for repeal
will not be published. The sections 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 Texas Department of Health (department) proposes the re-
peal of 33.501 - 33.506, concerning the Texas Health Steps
Medical Case Management.
The proposed new rules for Case Management for Children
and Pregnant Women will provide case management services
to Medicaid eligible women of all ages who have a high risk
pregnancy and to children from birth to 21 years of age with
a health condition/health risk. The programs, Medicaid Case
Management for High Risk Pregnant Women and High Risk
Infants and the Texas Health Steps Medical Case Manage-
ment will become one program due to the proposed repeal
of 32.301 - 32.305, 32.307, 33.501 - 33.506, and 37.81 -PROPOSED RULES April 4, 2003 28 TexReg 2869
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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/m1/48/: accessed June 6, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.