Section 371.1709 - Payment Hold(a) Subject to subsections (c) and (d) of this section, the OIG imposes a payment hold against a provider only: (1) to compel the production records or documents;(2) when requested by the state's Medicaid Fraud Control Unit; or(3) upon the determination a credible allegation of fraud exists.(b) The OIG may elect not to impose a payment hold, to discontinue a payment hold, to impose a payment hold only in part, or to convert a payment hold imposed in whole to one imposed only in part, for any of the good cause exceptions enumerated in RSA 455.23 and in Texas Government Code § RSA 531.102(g)(8).(c) The OIG may not impose a payment hold on claims for reimbursement submitted by a provider for medically necessary services for which the provider has obtained prior authorization from the commission or a contractor of the commission unless the OIG has evidence that the provider has materially misrepresented documentation relating to those services.(d) Unless the OIG receives a request from a law enforcement agency to temporarily withhold notice pursuant to RSA 455.23, the OIG shall provide notice as required by RSA 455.23(b) and Texas Government Code § RSA 531.102(g).(e) Scope and effect of payment hold. (1) Once a person is placed on payment hold, payment of Medicaid claims for specific procedures or services is limited or denied as long as the payment hold is in effect.(2) After a payment hold is terminated for any reason, the OIG may retain the funds accumulated during the payment hold to offset any overpayment, criminal restitution, penalty or other assessment, or agreed-upon amount that may result from ongoing investigation of the person, including any payment amount accepted by the prosecuting authorities made in lieu of a prosecution to reimburse the Medicaid or other HHS program.(3) The payment hold may be terminated or partially lifted for the reasons outlined in RSA 455.23 or Texas Government Code § RSA 531.102(g)(8).1 Tex. Admin. Code § 371.1709
The provisions of this §371.1709 adopted to be effective October 14, 2012, 37 TexReg 7989; Amended to be effective April 15, 2014, 39 TexReg 2833; Amended by Texas Register, Volume 40, Number 39, September 25, 2015, TexReg 6587, eff. 10/1/2015; Amended by Texas Register, Volume 41, Number 17, April 22, 2016, TexReg 2945, eff. 5/1/2016