Subchapter F, Claims Payment and Documentation
§47.81 Monitoring Medicaid Eligibility
(a) Applicability. This section does not apply to individuals who are receiving FC services.
(b) Verification of Medicaid eligibility. A provider must verify each month that an individual remains Medicaid eligible. The provider may verify the individual's current Medicaid eligibility by:
(1) viewing the individual's Health and Human Services Commission Medicaid Identification form; or
(2) using the current systems available to verify individual registration.
(c) Reimbursement. The provider is not entitled to payment from DADS for services delivered if the provider fails to verify the individual has current Medicaid eligibility.
§47.83 Monitoring Reviews
(a) Monitoring reviews. DADS conducts monitoring reviews in the PHC Program as described in Chapter 49 of this title (relating to Contracting for Community Care Services) and in this chapter.
(b) Fiscal monitoring. Fiscal monitoring in the PHC Program includes monitoring financial errors, which are applied to the entire unit of service. Financial errors include the following instances:
(1) DADS reimburses a provider for services, but the service delivery documentation is missing for the period for which services are reimbursed. DADS applies the error to the total number of units reimbursed for the pay period.
(2) DADS reimburses the provider for services, but the attendant fails to complete the units of service delivered portion of the service delivery documentation. DADS applies the error to the total number of units reimbursed for the pay period.
(3) DADS reimburses the provider for hours that exceed the total number of hours recorded on the service delivery documentation. DADS applies the error to the total number of units reimbursed in excess of the units recorded on the service delivery documentation. The lowest of the three totals in subparagraphs (A)-(C) of this paragraph is used to calculate the total number of hours recorded on the service delivery documentation:
(A) the sum of time in and time out;
(B) the sum of daily totals of time; or
(C) the total time recorded.
(4) DADS reimburses the provider for units of service for days on which the individual did not receive services. DADS applies the error to the total number of units reimbursed for the day on which the individual did not receive services.
(5) DADS reimburses the provider for units of service for days on which the individual was Medicaid ineligible. DADS applies the error to the total number of units reimbursed for the days on which the individual was Medicaid ineligible. This paragraph does not apply to FC services.
§47.85 Retroactive Payment Procedures
(a) Applicability.
(1) This section does not apply to family care services.
(2) A provider agency that chooses to request retroactive payment must comply with the requirements of this section.
(b) Definition of retroactive payment. A retroactive payment is payment by the Texas Department of Human Services (DHS) to a provider agency for services under the Primary Home Care Program that are provided before the date the case manager determines the person's eligibility for the services.
(c) Reimbursement.
(1) The provider agency may be reimbursed for services provided before the date a completed, signed, and dated copy of DHS's Application for Assistance — Aged and Disabled form is received:
(A) for up to three months for a person who does not have Medicaid eligibility at the time of the request for retroactive payment; and
(B) for an indefinite period for a person who is Medicaid eligible at the time of the request for retroactive payment.
(2) DHS only reimburses the provider agency for the:
(A) services described in §47.41 of this chapter (relating to Allowable Tasks);
(B) number of hours of services allowed to be provided the person, calculated as described in §48.2918(c) of this title (relating to Eligibility for Primary Home Care); and
(C) allowable costs of the Primary Home Care Program, as described in 1 TAC, Chapter 355 (relating to Medicaid Reimbursement Rates).
(3) DHS will not reimburse the provider agency for the retroactive period if:
(A) the provider agency fails to submit the required documentation within the required time frames; or
(B) the person provided services does not meet the requirements described in subsection (d) of this section.
(d) Requirements before requesting retroactive payment. The provider agency may not request retroactive payment unless:
(1) the person appears to be Medicaid eligible as defined in §48.1201 of this title (relating to Definition of Program Terms);
(2) the provider agency obtains a practitioner's written statement as described in §47.47 of this chapter (relating to Medical Need Determination);
(3) the person requires at least one personal care task as described in §47.41 of this chapter; and
(4) the provider agency has verified and documented that the person is not already receiving services under the Primary Home Care Program from another provider agency.
(e) Pre-initiation activities. The provider agency must complete the pre-initiation activities described in §47.45(a) of this chapter (relating to Pre-Initiation Activities).
(f) Intake referral. On the day that the provider agency completes the pre-initiation activities, the provider agency must contact the local DHS office by telephone and make an intake referral by providing DHS information on the person to start the eligibility process.
(g) Service initiation. The provider agency must not begin to provide services to the person before the date the provider agency completes the pre-initiation activities and processes the intake referral as described in subsections (e) and (f) of this section.
(h) Requesting retroactive payment.
(1) A provider agency's written request for retroactive payment must include:
(A) a copy of the service plan required by subsection (e) of this section;
(B) a copy of DHS's Practitioner's Statement of Medical Need form; and
(C) the retroactive payment information, including the:
(i) "name of the provider agency;
(ii) contact information for the person;
(iii) date services were started;
(iv) tasks provided to the person. This includes both tasks allowed and not allowed by the Primary Home Care Program;
(v) weekly hours of service provided to the person. This includes hours allotted to tasks allowed and not allowed by the Primary Home Care Program; and
(vi) cost per hour of service charged to the person.
(2) The provider agency must submit the written request for retroactive payment:
(A) to the case manager or, if no case manager has been assigned, to DHS intake staff; and
(B) within seven days after the date the provider agency processes the intake referral.
(i) Charges to persons who receive services.
(1) The provider agency may charge a person for services for which the provider agency intends to request retroactive payment, unless the person is Medicaid eligible.
(2) The provider agency must reimburse the entire amount of all payments made by the person to the provider agency for eligible services, even if those payments exceed the amount DHS will reimburse for the services, if DHS determines that the person is eligible for the Primary Home Care Program.
(j) Documentation of retroactive payment requests. The provider agency must maintain documentation of retroactive payment requests in the person's file.
§47.87 Record Keeping
(a) General record keeping requirements. A provider must maintain records according to:
(1) Chapter 49 of this title (relating to Contracting for Community Care Services);
(2) Chapter 69 of this title (relating to Contract Administration);
(3) the terms of the contract;
(4) this chapter; and
(5) the provider's company policies.
(b) Program specific records. A provider must maintain records of compliance with the requirements of this chapter.
(c) Financial records. A provider must maintain financial records:
(1) to support its billings to DADS for payment under §47.89 of this chapter (relating to Reimbursement);
(2) to document reimbursements made by DADS, including:
(A) amount of reimbursement;
(B) voucher number;
(C) the warrant number;
(D) the date of receipt of the reimbursement; and
(E) any other information necessary to trace deposits of reimbursements and payments made from the reimbursements in the provider's accounting system; and
(3) in accordance with generally accepted accounting principles (GAAP) and DADS procedures, including:
(A) deposit slips, bank statements, cancelled checks, and receipts;
(B) purchase orders;
(C) invoices;
(D) journals and ledgers;
(E) payroll and tax records;
(F) service delivery documentation;
(G) Internal Revenue Service, Department of Labor, and other government records and forms;
(H) records of insurance coverage, claims, and payments (for example, medical, liability, fire and casualty, and workers' compensation);
(I) equipment inventory records;
(J) records of the provider's internal accounting procedures; and
(K) a chart of accounts, as defined by GAAP.
(d) Subcontractor records. If a provider utilizes a subcontractor, the provider must maintain records of the subcontractor's activities. Maintaining all records to support subcontractor claims is the responsibility of the provider.
(e) Failure to maintain records. Failure to maintain records as specified in this section may result in:
(1) corrective action plans;
(2) monetary exceptions; or
(3) other actions deemed necessary or appropriate by DADS.
§47.89 Reimbursement
(a) Billing requirements.
(1) A provider must bill for services provided as described in §49.41 of this title (relating to Billings and Claims Payment).
(2) The provider must not bill DADS for:
(A) more hours than an individual's weekly authorization, except when services are delivered as described in §47.63(a) of this chapter (relating to Service Delivery);
(B) services delivered in a licensed facility, if the facility is required by the license to provide those services; and
(C) services or tasks that duplicate any services or tasks provided to the individual by another source.
(b) Hourly rate. The provider must agree to accept the hourly rate authorized by DADS
(c) Documentation. The provider must maintain the documentation described in this chapter to be eligible for reimbursement.
(d) Rounding. The provider must bill DADS for services in quarter-hour increments, rounding up to the next quarter-hour if the actual time worked is eight minutes or more, and rounding down to the previous quarter hour if the actual time worked is seven minutes or less.
(e) Allowable tasks. The provider must bill DADS only for the tasks described in §47.41 of this chapter (relating to Allowable Tasks).