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Texas Government Code - GOV'T § 544.0504. Recovery Audit Contractors

Current as of January 01, 2024 | Updated by Findlaw Staff

To the extent required under Section 1902(a)(42), Social Security Act (42 U.S.C. Section 1396a(a)(42)), the commission shall establish a program under which the commission contracts with one or more recovery audit contractors to identify Medicaid underpayments and overpayments and recover the overpayments.

(a) To the extent required under Section 1902(a)(42), Social Security Act (42 U.S.C. Section 1396a(a)(42)), the commission shall establish a program under which the commission contracts with one or more recovery audit contractors to:

(1) identify Medicaid underpayments and overpayments, including underpayments and overpayments under the Medicaid managed care program;  and

(2) recover the overpayments.

(b) An overpayment under Subsection (a)(2) may be recovered from either the provider or the managed care organization.

(c) A recovery audit contractor may not:

(1) initiate a review of a claim unless:

(A) the office of inspector general or the office's designee:

(i) determines that the review would be cost-effective;  and

(ii) approves the review;  and

(B) at least one year has elapsed since the date the claim was received;  or

(2) initiate a recovery effort on a claim if a managed care organization has notified the office of inspector general that the organization is auditing the claim.

(d) On request by a recovery audit contractor or the office of inspector general, a managed care organization or provider who is the subject of a review conducted under this section shall submit to the contractor or office all information necessary to perform the review not later than the date specified in the request.  All information and materials obtained under this section are confidential under Section 544.0259(e).

(e) The executive commissioner by rule shall adopt a process for appeals related to overpayments identified by a recovery audit contractor under this section.

(f) The commission may contract with a third party to administer Subsection (b) or the appeals process adopted under Subsection (e).

(g) The executive commissioner, in consultation with the office of inspector general, may adopt rules necessary to implement this section.

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Cite this article: FindLaw.com - Texas Government Code - GOV'T § 544.0504. Recovery Audit Contractors - last updated January 01, 2024 | https://codes.findlaw.com/tx/government-code/gov-t-sect-544-0504/

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