Section 371.201 - Case Selection Process(a) HHSC selects TMRP cases for review by a statistically valid random sampling methodology and/or focused case selection. Cases consist of paid inpatient claims for diagnosis-related groups (DRGs), which may include: (1) readmissions up to 30 days;(2) ambulatory surgical procedures billed on inpatient claims;(3) questionable admissions or claims coding identified by other entities;(4) admissions identified through HHSC's quality review program as potential quality of care concerns;(5) DRG payments made to freestanding rehabilitation facilities;(6) day or cost outlier payments; or(7) any other DRG or claims submission errors.(b) HHSC selects TEFRA and facility-specific per diem methodology cases for review by a statistically valid random sampling methodology and/or focused case selection. Cases consist of paid inpatient claims for admissions to children's hospitals and freestanding psychiatric facilities.1 Tex. Admin. Code § 371.201
The provisions of this §371.201 adopted to be effective January 1, 1993, 17 TexReg 8457; transferred effective September 1, 1993, as published in the Texas Register January 28, 1994, 19 TexReg 589; Amended to be effective July 27, 1994, 19 TexReg 5493; Amended to be effective November 22, 1995, 20 TexReg 9274; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000, 25 TexReg 1308; Amended to be effective March 30, 2003, 28 TexReg 2481; Amended to be effective January 1, 2014. 38 TexReg 9479; Amended by Texas Register, Volume 41, Number 17, April 22, 2016, TexReg 2943, eff. 5/1/2016