Texas Register, Volume 38, Number 40, Pages 6747-6996, October 4, 2013 Page: 6,759
6747-6996 p. ; 28 cm.View a full description of this periodical.
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(b) When an admission denial or day of stay denial is issued,
the Commission will direct the claims administrator to recoup pay-
ment. If a hospital claim is denied for lack of medical necessity or
for being provided in an inappropriate setting, the Commission will
consider for denial physician and/or non-physician Medicaid provider
claims associated with the hospital admission or service when such
claims can be identified and are deemed to be the result of inappro-
priate admission orders. The Commission will make an exception in
the case of TMRP hospitals if the patient was [originally] placed in
observation, and the Commission [hospital has been] notified [by] the
hospital [Commission] that it [they] may submit a revised outpatient
claim solely for medically necessary outpatient services provided dur-
ing the Texas Medicaid Provider Procedures Manual (TMPPM), or any
subsequent provider manuals, defined observation period. A physi-
cian's order for observation must be present in the physician's orders
to document that the patient was originally ] placed in outpatient ob-
servation. The hospital must submit the revised outpatient claim and a
copy of the Commission's notification letter to the claims administrator
at the address indicated in the notification letter. The claims adminis-
trator must receive the outpatient claim and copy of the notification
letter within 120 [one hundred twenty] calendar days of the date of the
notification letter. The claims administrator may consider payment for
the medically necessary services provided during the TMPPM-defined
[twenty-four hour] observation period. The hospital may provide ob-
servation services in any part of the hospital where a patient can be
assessed, monitored, and treated.
371.210. Inpatient Utilization Review for Hospitals Reimbursed
Under the Tax Equity and Fiscal Responsibility Act (TEFRA) Princi-
ples of Reimbursement, and Facility-Specific Per Diem Methodology
Reviews [or LoneS TR Select 14Contracting PrgramJ.
(a) The TEFRA and facility-specific per diem methodology re-
views [LoneSTAR Selet H contract review] process includes the fol-
lowing:
(1) Admission review to evaluate the medical necessity of
the admission. For purposes of the Texas Medical Review Program
(TMRP), TEFRA[, and LoneSTAR Select H contract] reviews, medical
necessity means the patient has a condition requiring treatment that can
be safely provided only in the inpatient setting.
(2) Continued stay review to verify the medical necessity
of each day of stay.
(3) Quality of care review to assess whether the quality of
care provided meets generally accepted standards of medical and hos-
pital care practices or puts the patient at risk of unnecessary injury or
death. Quality of care review includes the use of discharge screens
and generic quality screens. If quality of care issues are identified,
physician consultants under contract with the Texas Health and Hu-
man Services Commission (Commission), and of the specialty related
to the care provided, will determine possible clinical recommendations
or corrective actions.
(b) The Commission will review the complete medical record
for the requested admission(s) to make decisions on all aspects of this
review process. The complete medical record may include: emergency
room records, medical/surgical history and physical examination, dis-
charge summary, physicians' progress notes, physicians' orders, lab re-
ports, diagnostic and imaging [x-ray] reports, operative reports, pathol-
ogy reports, nurses' notes, medication sheets, vital signs sheets, therapy
notes, specialty consultation reports, and special diagnostic and treat-
ment records. If the complete medical record is not available during
the review, the Commission will issue a preliminary technical denial
and notify the facility.(c) A physician consultant under contract with the Commis-
sion will make all decisions concerning medical necessity, cause of
readmission, and appropriateness of setting for the service provided.
In the event the physician consultant determines the services were not
medically necessary, should have been provided in a previous admis-
sion, or were not provided in the appropriate setting, the claim will
be denied, and the Commission will notify the hospital in writing. If
a hospital claim is denied for lack of medical necessity or for being
provided in an inappropriate setting, the Commission will consider for
denial physician and/or non-physician Medicaid provider claims asso-
ciated with the hospital admission or service when such claims can be
identified and are deemed to be the result of inappropriate admission
orders. Physicians and/or non-physician providers will be notified in
writing if the claim for professional services is denied. The written no-
tification will explain the process for appealing the denial.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal author-
ity to adopt.
Filed with the Office of the Secretary of State on September 23,
2013.
TRD-201304203
Steve Aragon
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: November 3, 2013
For further information, please call: (512) 424-6900
TITLE 4. AGRICULTURE
PART 2. TEXAS ANIMAL HEALTH
COMMISSION
CHAPTER 38. TRICHOMONIASIS
4 TAC 38.2
The Texas Animal Health Commission (commission) proposes
amendments to 38.2, concerning General Requirements, in
Chapter 38, which is entitled "Trichomoniasis". The purpose of
the amendments is to change the testing requirements for bulls.
Bovine Trichomoniasis (Trich) is a venereal disease of cattle
caused by the protozoa Tritrichomonas foetus. Certain herd
management practices such as commingled grazing or fence-
line contact with other herds are risk factors for infection. Control
of T foetus in an infected herd includes testing bulls and culling
those infected.
Representatives of the Bovine Trich Working Group met on May
21, 2013, at the commission's central office in Austin to review
and evaluate the effectiveness of current rules. The group rec-
ommended allowing untested bulls to be purchased and resold
without a test if moved under permit with official permanent iden-
tification. After much discussion it was decided that this proce-
dure will be allowed. Commission inspectors will permit untested
bulls to be moved to either a feeding facility, another sale barn
or to another physical location given by the buyer for the bull
to be resold. The permit will expire seven days from the date
of issuance and bulls cannot be commingled with female cattle
during the seven days.
FISCAL NOTEPROPOSED RULES October 4, 2013 38 TexReg 6759
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Texas. Secretary of State. Texas Register, Volume 38, Number 40, Pages 6747-6996, October 4, 2013, periodical, October 4, 2013; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth342082/m1/13/: accessed April 24, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.