Texas Register, Volume 14, Number [6], Pages 329-475, January 20, 1989 Page: 342

                                
denial by DHS or its contractor was incor-
rect. The hospital may submit copies of any
documentation the hospital deems neces--
sary. Appeals of technical denials must be
received no later td a 15 days from the date
of the final technical denial notice firo
DHS or its contractor and must be sent to
the DHS Heaarings Division.
(B) if thle r'equixrnenrts of
subparagraph (A) of this paragraph are met,
DHS renders a decision on DHIS' or fle
contractor's technical denial decision. Ki
DHS detennrmines that the technical denial
was correct, DHS considers the decision of
DHS or the eio ra ctor as final. If DHS1
determines that DRS' or its contractor's
decision was incorrect, DHS notifies the
hospital that the technical denial has bean
overturned. A medical necessity review and
DRG review   will then be performed by
DHS or its contractor.
(C) If the hospital deteirrines
that DHS has rendered an incorrect decision
concerning the technical denial appeal, the
hospital may request a formal contract ap-
peal in accordance with the requirements of
paragraph (1)(C) of this section.
41.111. Sanctions ulder the TMRP and
TEFRA. DHS may impose administrative
sanctions against hospitals or physicians un-
der the TMRP and TEFRA in accordance
with Chapter 79, Subchapter V of this title
(relating to Fraud and Abuse Involving
Medical Providers).

41.112. Inpatient Utilization Review for
Hospitals Reimbursed under the Tax Equity
Fiscal Responsibility Act (TEFRA) Princi-
pies of' Reinbursenert.
(a) For all Medicaid cdmissions
identified for review, thc I EFRA review
process coneists of tiBe following three ma-
jor comparoenus:
(1)  admission review, which is a
detennrination of the medical necessity of
the admissiona;
(2)  count ,'hruecd  stay  review,
which is the detrCmnb ation of the medical
necessity of each day of stay;
(3)  quality  of  et ar  review,
which is an asstessrment of the quality of
care provided to determine if it meats gen-
erally accepted standards of medical and
110ospital care practices or puts the patien at
risk of unnecessary hijury or dead. Quality
of care review includes the use of discharge
creens and generic quality screens.
(b) DHS staff will review thf corm-
plete medical record to make decisions con-
crnirng  the medical necessity   of the
admission, continued stay, rnd maylity.
(c) If the complete r-a  'i record
is not available oz is not made available
during the review, a prelim in y technical
denial will he issued. The facility will be
notified and allowed 30 days to provide the
complete medical record to DIS. If the
complete medical record is received by
DHS within the 30 days, a final technical
denial is not issued and the medical record

is reviewed. If the complete medical record
is not received by DHS wihin t he 30 days,
a final technical denial  is issued, and pay-
ment is recouped.
(d) VlWhen  n admission denial or a
denial of continued stay is issued, or when a
technical denial becomes final, DHS will
recoup all monies paid to the hospital for
the admission or for the days of stay that
were denied.
41.113. Qa'rlity of Care Revi kev. Quality
review will be conducted en all cases re-
viewed by DHS or it- contractor. DHS or a
ontractor physician may ideatify quality
issues. DHS will utilize regional and state-
wide quality review cojrnittees to make
recommendations to DHS concerning cor-
rctive actions and/or sanctions. The com-
mittees will ba comprised of tOire to five
specialty consultant physicians from  the
same geographic location as the hospital,
when possiNbe. The DHS physician will
serve as ain ex officio member of de com-
rnittes.
Issued in Austin, Texas, on Janraty 12, 1989.

TRD-9eo28a0

Chiaes Stavonson
Actir Commisrioner
l oxes Department of
Humn Serviocas

Effective date: January 12, 1989
Expiration date: May 12, 1989

For further
450-3765

information, please call: (512)

14 TexReg 342    January 20, 1989   Texas Register *

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