Selection of cases for review includes, but is not limited to:

1. (1) Texas Medical Review Program (TMRP) cases:

   1. (A) 3.0% random sample per hospital; up to 100% focused review for specific diagnostic related groups (DRGs); readmissions up to 30 days; day surgery billed as inpatient; questionable admissions or coding identified by other entities; transfers to nonprospective payment system (PPS) hospitals; admissions identified through the quality review program as potential quality-of-care concerns;

   2. (B) additional cases, up to 100% for any provider or DRG, if:

      1. (i) admission denials statewide for a given DRG are 5.0% or greater; or
      2. (ii) admission denials for a particular provider are 5.0% or greater; or
      3. (iii) admission denials for a given DRG for a particular provider are 5.0% or greater; or
      4. (iv) DRG changes statewide for a given DRG are 10% or greater; or
      5. (v) DRG changes for a particular provider are 10% or greater; or
      6. (vi) DRG changes for a given DRG for a particular provider are 10% or greater;

2. (2) Tax Equity and Fiscal Responsibility Act (TEFRA) cases:

   1. (A) up to a 15% sample for each TEFRA hospital. This sample includes, but is not limited to, a 10% random sample of hospitals and 5.0% of admissions comprised of focused review based on identified problem areas (that is, diagnoses or procedures, transfers, day of admission, day of discharge, etc.);

   2. (B) 100% of cases in a quarter for any provider, if:

      1. (i) inappropriate transfers from TEFRA hospitals to PPS hospitals are identified; or
      2. (ii) admission denials are 5.0% or greater for the provider; or
      3. (iii) continued stay denials are 10% or greater for that provider.

Source Note: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.