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Texas Human Resources Code - Section 32.0291. Prepayment Reviews And Postpayment Holds

Legal Research Home > Texas Laws > Human Resources Code > Texas Human Resources Code - Section 32.0291. Prepayment Reviews And Postpayment Holds

§ 32.0291. PREPAYMENT REVIEWS AND POSTPAYMENT HOLDS.  (a) 
Notwithstanding any other law, the department may:
		(1)  perform a prepayment review of a claim for 
reimbursement under the medical assistance program to determine 
whether the claim involves fraud or abuse;  and
		(2)  as necessary to perform that review, withhold 
payment of the claim for not more than five working days without 
notice to the person submitting the claim.
	(b)  Notwithstanding any other law, the department may 
impose a postpayment hold on payment of future claims submitted by a 
provider if the department has reliable evidence that the provider 
has committed fraud or wilful misrepresentation regarding a claim 
for reimbursement under the medical assistance program.  The 
department must notify the provider of the postpayment hold not 
later than the fifth working day after the date the hold is imposed.
	(c)  On timely written request by a provider subject to a 
postpayment hold under Subsection (b), the department shall file a 
request with the State Office of Administrative Hearings for an 
expedited administrative hearing regarding the hold.  The provider 
must request an expedited hearing under this subsection not later 
than the 10th day after the date the provider receives notice from 
the department under Subsection (b).  The department shall 
discontinue the hold unless the department makes a prima facie 
showing at the hearing that the evidence relied on by the department 
in imposing the hold is relevant, credible, and material to the 
issue of fraud or wilful misrepresentation.
	(d)  The department shall adopt rules that allow a provider 
subject to a postpayment hold under Subsection (b) to seek an 
informal resolution of the issues identified by the department in 
the notice provided under that subsection.  A provider must seek an 
informal resolution under this subsection not later than the 
deadline prescribed by Subsection (c).  A provider's decision to 
seek an informal resolution under this subsection does not extend 
the time by which the provider must request an expedited 
administrative hearing under Subsection (c).  However, a hearing 
initiated under Subsection (c) shall be stayed at the department's 
request until the informal resolution process is completed.

Added by Acts 2003, 78th Leg., ch. 198, § 2.103, eff. Sept. 1, 
2003.     

Last modified: August 11, 2007