Sec. 531.109. SELECTION AND REVIEW OF CLAIMS. (a) The commission shall annually select and review a random, statistically valid sample of all claims for reimbursement under Medicaid, including under the vendor drug program, for potential cases of fraud, waste, or abuse.
(b) In conducting the annual review of claims under Subsection (a), the commission may directly contact a recipient by telephone or in person, or both, to verify that the services for which a claim for reimbursement was submitted by a provider were actually provided to the recipient.
(c) Based on the results of the annual review of claims, the commission shall determine the types of claims at which commission resources for fraud and abuse detection should be primarily directed.
(d) Absent an allegation of fraud, waste, or abuse, the commission may conduct an annual review of claims under this section only after the commission has completed the prior year's annual review of claims.
Added by Acts 1999, 76th Leg., ch. 1289, Sec. 4, eff. Sept. 1, 1999.
Amended by:
Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.04(c), eff. September 28, 2011.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.145, eff. April 2, 2015.
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