Tex. Gov't Code Section 544.0503
Process for Managed Care Organizations to Recoup Overpayments Related to Electronic Visit Verification Transactions

(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 the organization conducts secondary to missing electronic visit verification information. The rules must require that the organization:

(1)

provide written notice to a provider:

(A)

of the organization’s intent to recoup overpayments not later than the 30th day after the date an audit is complete;

(B)

of the specific claims and electronic visit verification transactions that are the basis of the overpayment;

(C)

of the process the provider should use to communicate with the organization to provide information about the electronic visit verification transactions;

(D)

of the provider’s option to seek an informal resolution of the alleged overpayment;

(E)

of the process to appeal the determination that an overpayment was made; and

(F)

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; and

(2)

limit the duration of audits to 24 months.

(b)

Notwithstanding any other law, a managed care organization may not attempt to recover an overpayment described by Subsection (a) until the provider exhausts all rights to an appeal.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.

Source: Section 544.0503 — Process for Managed Care Organizations to Recoup Overpayments Related to Electronic Visit Verification Transactions, https://statutes.­capitol.­texas.­gov/Docs/GV/htm/GV.­544.­htm#544.­0503 (accessed Jun. 5, 2024).

544.0001
Definitions 544.0002
Reference to Office of Investigations and Enforcement 544.0003
Authority of State Agency or Governmental Entity Not Limited 544.0051
Coordination with Office of Attorney General 544.0052
Rules Regarding Enforcement and Punitive Actions 544.0053
Provision of Information to Pharmacy Subject to Audit 544.0054
Records of Allegations of Fraud or Abuse 544.0055
Record and Confidentiality of Informal Resolution Meetings 544.0056
Expunction of Child’s Chemical Dependency Diagnosis in Certain Records 544.0101
Appointment of Inspector General 544.0102
Commission Powers and Duties Related to Office of Inspector General 544.0103
Office of Inspector General: General Powers and Duties 544.0104
Employment of Medical Director 544.0105
Employment of Dental Director 544.0106
Contract for Review of Investigative Findings by Qualified Expert 544.0107
Employment of Peace Officers 544.0108
Investigative Process Review 544.0109
Performance Audits and Coordination of Audit Activities 544.0110
Reports on Audits, Inspections, and Investigations 544.0111
Compliance with Federal Coding Guidelines 544.0112
Hospital Utilization Reviews and Audits: Provider Education Process 544.0113
Program Exclusions 544.0114
Report 544.0151
Definitions 544.0152
Exchange of Criminal History Record Information Between Participating Agencies 544.0153
Provider Eligibility for Medicaid Participation: Criminal History Record Information 544.0154
Monitoring of Certain Federal Databases 544.0155
Period for Determining Provider Eligibility for Medicaid 544.0201
Selection and Review of Medicaid Claims to Determine Resource Allocation 544.0202
Duties Related to Fraud Prevention 544.0203
Fraud, Waste, and Abuse Detection Training 544.0204
Health and Human Services Agency Medicaid Fraud, Waste, and Abuse Detection Goal 544.0205
Award for Reporting Medicaid Fraud, Abuse, or Overcharges 544.0251
Claims Criteria Requiring Commencement of Investigation 544.0252
Circumstances Requiring Commencement of Preliminary Investigation of Alleged Fraud or Abuse 544.0253
Conduct of Preliminary Investigation of Alleged Fraud or Abuse 544.0254
Finding of Certain Medicaid Fraud or Abuse Following Preliminary Investigation: Criminal Referral or Full Investigation 544.0255
Immediate Criminal Referral Under Certain Circumstances 544.0256
Continuation of Payment Hold Following Referral to Law Enforcement Agency 544.0257
Completion of Full Investigation of Alleged Medicaid Fraud or Abuse 544.0258
Memorandum of Understanding for Assisting Attorney General Investigations Related to Medicaid 544.0259
Subpoenas 544.0301
Imposition of Payment Hold 544.0302
Notice 544.0303
Expedited Administrative Hearing 544.0304
Informal Resolution 544.0305
Website Posting 544.0351
Applicability of Subchapter 544.0352
Special Investigative Unit or Contracted Entity to Investigate Fraud and Abuse 544.0353
Fraud and Abuse Prevention Plan 544.0354
Assistance and Oversight by Office of Inspector General 544.0355
Rules 544.0401
Definition 544.0402
False or Misleading Information Related to Financial Assistance Eligibility 544.0403
Commission Action Following Determination of Violation 544.0404
Ineligibility for Financial Assistance Following Violation 544.0405
Household Eligibility for Financial Assistance Not Affected 544.0406
Rules 544.0451
Learning, Neural Network, or Other Technology Relating to Medicaid 544.0452
Medicaid Fraud Investigation Tracking System 544.0453
Medicaid Fraud Detection Technology 544.0454
Data Matching Against Federal Felon List 544.0455
Electronic Data Matching 544.0456
Methods to Reduce Fraud, Waste, and Abuse in Certain Public Assistance Programs 544.0501
Recovery Monitoring System 544.0502
Payment Recovery Efforts by Certain Persons 544.0503
Process for Managed Care Organizations to Recoup Overpayments Related to Electronic Visit Verification Transactions 544.0504
Recovery Audit Contractors 544.0505
Annual Report on Certain Fraud and Abuse Recoveries 544.0506
Notice and Informal Resolution of Proposed Recoupment of Overpayment or Debt 544.0507
Appeal of Determination to Recoup Overpayment or Debt
Green check means up to date. Up to date

Accessed:
Jun. 5, 2024

§ 544.0503’s source at texas​.gov