TITLE 1. ADMINISTRATION

PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION

CHAPTER 371. MEDICAID FRAUD AND ABUSE PROGRAM INTEGRITY

SUBCHAPTER C. UTILIZATION REVIEW

1 TAC §§371.200 - 371.214

Senate Bill 30, §1.07, 75th Legislative Session transferred the responsibility for utilization review in the state Medicaid program from the Texas Department of Health and the Texas Department of Human Services to the Texas Health and Human Services Commission. In accordance with this transfer, Title 25, Part 1, §§41.101 - 41.105 and 41.107 - 41.113 concerning utilization review will become Title 1, Part 15, §§371.200 - 371.211, effective September 1, 1997. Title 40, Part 1, §§19.1812, 19.2411, and 19.2412 will become Title 1, Part 15, §§371.212 - 371.214, effective September 1, 1997.

Figure: 1 TAC Chapter 371

§371.200.Inpatient Hospital Utilization Review Program.

§371.201.Case Selection Process.

§371.202.Contracting for Texas Medical Review Program (TMRP) or Tax Equity and Fiscal Responsibility (TEFRA) Services.

§371.203.Texas Medical Review Program (TMRP) Review Process.

§371.204.TMRP Hospital Screening Criteria for TMRP and TEFRA Reviews.

§371.205.Acknowledgment of Penalty Notice.

§371.206.Denials and Recoupments for Texas Medical Review Program (TMRP) and Tax Equity and Fiscal Responsibility Act (TEFRA) Hospitals.

§371.207.Diagnostic Related Group (DRG) Changes and Adjustments.

§371.208.Appeals Requirements under the Texas Medical Review Program (TMRP) and Tax Equity and Fiscal Responsibility Act (TEFRA), and Hospital Notification.

§371.209.Sanctions under the TMRP and TEFRA.

§371.210.Inpatient Utilization Review for Hospitals Reimbursed under the Tax Equity and Fiscal Responsibility Act (TEFRA) Principles of Reimbursement.

§371.211.Quality of Care Review.

§371.212.Case Mix Classification.

§371.213.Utilization Review and Control Activities Performed by Texas Department of Human Services (DHS).

§371.214.Texas Index for Level of Effort (TILE) Assessments.