Section 371.1311 - Role of the OIG and SIUs(a) An MCO is required by § RSA 353.502 of this title (relating to Managed Care Organization's Plans and Responsibilities in Preventing and Reducing Waste, Abuse, and Fraud) and § RSA 370.501 of this title (relating to Purpose) to establish and maintain an SIU to investigate allegations of waste, abuse, or fraud for all services in the MCO plan. If an MCO suspects possible waste, abuse, or fraud, the MCO must conduct a preliminary investigation in accordance with criteria in § RSA 353.502 and § RSA 370.501 of this title. If the preliminary investigation confirms waste, abuse, or fraud , the MCO must refer the matter to the OIG in accordance with § RSA 353.505 of this title (relating to Recovery of Funds).(b) For a potential overpayment amount less than $100,000, the MCO pursues recovery of the overpayment, and remits one-half of the recovered amount in accordance with § RSA 353.505 of this title (relating to Recovery of Funds).(c) For MCO referrals to the OIG where the potential overpayment amount exceeds $100,000, the OIG accepts the referral and conducts a preliminary investigation. (1) The OIG evaluates the allegation(s) and evidence from the MCO-SIU for intentional deception, repeat billing pattern, or other indicators of questionable practices.(2) The OIG determines within 30 business days whether to take additional investigative action, and notifies the referring MCO of the decision.(d) If the preliminary investigation determines a full investigation is warranted, the OIG assesses the provider's billing activity in fee-for-service Medicaid and other MCOs in which the provider is credentialed.1 Tex. Admin. Code § 371.1311
Adopted by Texas Register, Volume 41, Number 17, April 22, 2016, TexReg 2944, eff. 5/1/2016; Amended by Texas Register, Volume 44, Number 28, July 12, 2019, TexReg 3544, eff. 7/18/2019