PROCESS FOR MANAGED CARE ORGANIZATIONS TO RECOUP OVERPAYMENTS RELATED TO ELECTRONIC VISIT VERIFICATION TRANSACTIONS.
Tex. GOV'T Code § 544.0503.
in effect(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.