1. (a) The Texas Health and Human Services Commission (Commission) selects Texas Medical Review Program (TMRP) cases for review by a statistically valid random sampling methodology and/or focused case selection. Cases will consist of paid inpatient claims for diagnostic related groups (DRGs), which may include:

   1. (1) Readmissions up to 30 days;
   2. (2) Ambulatory surgical procedures billed on inpatient claims;
   3. (3) Questionable admissions or claims coding identified by other entities;
   4. (4) Admissions identified through the Commission's quality review program as potential quality of care concerns;
   5. (5) DRG payments made to freestanding rehabilitation facilities;
   6. (6) Day or cost outlier payments; or
   7. (7) Any other DRG or claims submission errors.
2. (b) The Commission selects Tax Equity and Fiscal Responsibility Act and facility specific per diem methodology cases for review by a statistically valid random sampling methodology and/or focused case selection. Cases will consist of paid inpatient claims for admissions to children's hospitals and freestanding psychiatric facilities.

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; amended to be effective March 30, 2003, 28 TexReg 2481; amended to be effective January 1, 2014. 38 TexReg 9479.