1. (a) If a managed care organization (MCO) decides to recoup an overpayment from a provider or FMSA because of a discovery of fraud or abuse as permitted by §353.505 of this chapter (relating to Recovery of Funds), the MCO must have due process procedures that include the following:

   1. (1) written notice to the provider or FMSA of the MCO's intent to recoup overpayments that includes the following:

      1. (A) a description of the basis for the intended recoupment;
      2. (B) the specific claims that are the basis of the intended recoupment;
      3. (C) the process by which the provider or FMSA should send information to the MCO about claims that are the basis of the intended recoupment;
      4. (D) the provider's or FMSA's option to seek an informal resolution with the MCO of the intended recoupment; and
      5. (E) the MCO's process for the provider or FMSA to appeal the intended recoupment;
   2. (2) a process for the provider or FMSA to seek informal resolution; and
   3. (3) a process for the provider or FMSA to appeal the intended recoupment.

2. (b) An MCO may recoup an overpayment only if a provider or FMSA:

   1. (1) does not appeal the alleged overpayment; or
   2. (2) appeals the alleged overpayment and the final decision from the appeal is favorable to the MCO.

Source Note:The provisions of this §353.1454 adopted to be effective February 7, 2022, 47 TexReg 496.