Section 544.0503 - [Effective 4/1/2025] Process For Managed Care Organizations To Recoup Overpayments Related To Electronic Visit Verification Transactions(a) The executive commissioner shall adopt rules that standardize the process by which a managed care organization collects alleged overpayments that are made to a health care provider and discovered through an audit or investigation the organization conducts secondary to missing electronic visit verification information. The rules must require that the organization: (1) provide written notice to a provider: (A) of the organization's intent to recoup overpayments not later than the 30th day after the date an audit is complete;(B) of the specific claims and electronic visit verification transactions that are the basis of the overpayment;(C) of the process the provider should use to communicate with the organization to provide information about the electronic visit verification transactions;(D) of the provider's option to seek an informal resolution of the alleged overpayment;(E) of the process to appeal the determination that an overpayment was made; and(F) if the provider intends to respond to the notice, that the provider must respond not later than the 30th day after the date the provider receives the notice; and(2) limit the duration of audits to 24 months.(b) Notwithstanding any other law, a managed care organization may not attempt to recover an overpayment described by Subsection (a) until the provider exhausts all rights to an appeal. (Gov. Code, Sec. 531.1135.)Tex. Gov't. Code § 544.0503
Added by Acts 2023, Texas Acts of the 88th Leg.- Regular Session, ch. 769,Sec. 1.01, eff. 4/1/2025.