Texas Register, Volume 38, Number 9, Pages 1269-1452, March 1, 2013 Page: 1,287
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program, the funds and distribution of DSH payments will be made as
determined by HHSC.
(i) Hospital located in a federal natural disaster area. A hospi-
tal that is located in a county that is declared a federal natural disaster
area and that was participating in the DSH program at the time of the
natural disaster may request that HHSC determine its DSH qualifica-
tion and interim reimbursement payment amount under this subsection
for subsequent DSH program years. The following conditions and pro-
cedures will apply to all such requests received by HHSC:
(1) The hospital must submit its request in writing to HHSC
with its annual DSH application.
(2) If HHSC approves the request, HHSC will determine
the hospital's DSH qualification using the hospital's data from the DSH
data year prior to the natural disaster. However, HHSC will calculate
the one percent Medicaid minimum utilization rate, the interim hospi-
tal-specific limit, and the payment amount using data from the DSH
data year. The final hospital-specific limit will be computed based on
the actual data for the DSH program year.
(3) HHSC will notify the hospital of the qualification and
interim reimbursement.
(j) Review of HHSC determination of eligibility or[;] qualifi-
cation[- and estimated payment amount].
(1) Prior to the first payment of the DSH program year,
HHSC will notify each hospital that applied to participate in the DSH
program whether it is eligible and qualified to participate. [An eligi-
le hospital wil be notified of its estimated annual DS tallo nation
ealtculated as described in subsections (g)(12) and (h)(2) -(6) of this
section]
(2) A hospital that either does not qualify or is ineligible
[disputes the payment amount] may request a review by HHSC in ac-
cordance with paragraph (3) of this subsection. Initial qualification and
eligibility determinations [and estimated payment amounts for all hos-
pitals] may change depending on the outcome of the review.
(3) Except as specified in paragraph (6) of this subsection, a
request for review must be submitted in writing to HHSC within 30 [-5]
calendar days of the date the hospital received the notification under
this subsection.
(A) The written request for review and all supporting
documentation must be sent to HHSC's Director of Hospital Rate Anal-
ysis [Reimbursement], Rate Analysis Department.
(B) The request must allege the specific factual or cal-
culation errors the hospital contends HHSC made that, if corrected,
would result in the hospital's qualification or eligibility [qualifying] for
payments [or receiving a more accurate payment amount].
(C) A hospital may not base a request for review on a
claim that the data the hospital or a Medicaid contractor submitted to
HHSC is incorrect or incomplete data unless such incorrect or incom-
plete data would result in an inappropriate qualification or eligibility
[er payment to the hospital].
(i) The hospital will have an opportunity to resolve
disputed data with the Medicaid contractor under subsection (h)(1) of
this section.
(ii) HHSC may require supporting documentation
when a hospital requests a review based on data submitted with and
certified in a hospital's original DSH application.
(iii) HHSC may require an independent third party
audit of the revised data to be paid for by the hospital requesting thereview. The audit must be performed within the time frame determined
by HHSC.
(D) The request for review may not dispute HHSC's el-
igibility, qualification, or payment methodologies or the data submitted
by the Medicaid contractors. The review and adjudication of claims is
conducted between the hospital and the Medicaid contractors, prior to
the time frames identified in subsection (h)(1) of this section.
E) Within 30 calendar days of the date of the notifi-
eation, the hospital must submit documentation supporting its allega-
tions}j
(4) The review is:
(A) limited to the hospital's allegations of factual or cal-
culation errors;
(B) supported by documentation submitted by the hos-
pital or used by HHSC in making its original determination;
(C) solely a data review; and
(D) not an adversarial hearing.
(5) HHSC will notify the hospital of the results of the re-
view.
(6) HHSC will not consider requests for review submitted
after the deadline specified in paragraph (3) of this subsection unless
HHSC subsequently notifies a hospital that it no longer qualifies for
DSH funding. In that case, the hospital may request a review in accor-
dance with paragraph (3) of this subsection.
(k) Disproportionate share funds held in reserve.
(1) If HHSC has reason to believe that a hospital is not in
compliance with the conditions of participation listed in subsection (e)
of this section, HHSC will notify the hospital of possible noncompli-
ance. Upon receipt of such notice, the hospital will have 30 calendar
days to demonstrate compliance.
(2) If the hospital demonstrates compliance within 30 cal-
endar days, HHSC will not hold the hospital's DSH payments in re-
serve.
(3) If the hospital fails to demonstrate compliance within
30 calendar days, HHSC will notify the hospital that HHSC is holding
the hospital's DSH payments in reserve. HHSC will release the funds
corresponding to any period for which a hospital subsequently demon-
strates that it was in compliance. HHSC will not make DSH payments
for any period in which the hospital is out of compliance with the con-
ditions of participation listed in subsection (e)(1) and (2) of this sec-
tion. HHSC may choose not to make DSH payments for any period in
which the hospital is out of compliance with the conditions of partici-
pation listed in subsection (e)(3) - (7) of this section.
(4) If a hospital's DSH payments are being held in reserve
on the date of the last payment in the DSH program year, and no re-
quest for review is pending under paragraph (5) of this subsection, the
amount of the payments is not restored to the hospital, but is divided
proportionately among the hospitals receiving a last payment.
(5) Hospitals that have DSH payments held in reserve may
request a review by HHSC.
(A) The hospital's written request for a review must:
(i) be sent to HHSC's Director of Hospital Rate
Analysis [Reimbursement], Rate Analysis Department;PROPOSED RULES March 1, 2013 38 TexReg 1287
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Texas. Secretary of State. Texas Register, Volume 38, Number 9, Pages 1269-1452, March 1, 2013, periodical, March 1, 2013; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth308911/m1/19/: accessed May 6, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.