1. (a) HHSC pays a contractor for a claim for services that meets the requirements described in subsection (b) of this section.

2. (b) A contractor must ensure a claim for services is:

   1. (1) for a service that has been provided by a contractor;
   2. (2) a clean claim;
   3. (3) complete and accurate;

   4. (4) submitted within 12 months after one of the following, whichever is later:

      1. (A) the last day of the month in which the service was provided, the adaptive aid or medical supply delivered, or the minor home modification completed; or
      2. (B) the date the individual's eligibility for the service was determined;
   5. (5) for a type and amount of service that is authorized by HHSC;
   6. (6) for a service provided to an individual who is eligible for the service;
   7. (7) except as provided in HHSC rules governing services provided under the contract, for a service provided to an individual whose authorization for services has not been suspended or terminated by HHSC;
   8. (8) for a service provided during a time period authorized by HHSC;
   9. (9) for a service provided during the term of, and in accordance with, the contract, this subchapter, and HHSC rules governing services provided under the contract;
   10. (10) supported by records required by the contract and HHSC rules governing services provided under the contract;
   11. (11) for a service provided by a qualified service provider in accordance with HHSC rules governing services provided under the contract;
   12. (12) for a service ordered by a qualified practitioner, if required by the contract or HHSC rules governing services provided under the contract;
   13. (13) submitted in accordance with procedures required by HHSC rules governing services provided under the contract and by the claims administrator; and
   14. (14) not for a service that a source other than HHSC would have paid for if the contractor had submitted a proper, complete, and timely request for payment to the other source.
3. (c) As used in subsection (b)(11) and (12) of this section, the terms "qualified service provider" and "qualified practitioner" do not include a person whose health-related license has been suspended or revoked or who has been excluded from participation in a program administered under Title V, XVIII, XIX, or XX of the Social Security Act.
4. (d) HHSC denies a claim for services that does not meet the requirements in subsection (b) of this section and HHSC rules governing services provided under the contract. If HHSC denies a claim for services, a contractor may request and receive an administrative hearing.

5. (e) If a contractor or HHSC determines that the contractor received payment for a claim for services that does not meet the requirements in subsection (b) of this section and HHSC rules governing services provided under the contract:

   1. (1) the contractor may submit a corrected claim for services to allow HHSC to adjust amounts paid to a contractor, even if it is after the 12-month period described in subsection (b)(4) of this section; or
   2. (2) HHSC recoups funds paid to the contractor in accordance with §49.533 of this chapter (relating to Recoupment).
6. (f) If a claim for services is denied by HHSC, the contractor that submitted the claim may submit a corrected claim within the 12-month period described in subsection (b)(4) of this section.
7. (g) HHSC may adjust amounts paid to a contractor after the 12-month period described in subsection (b)(4) of this section.

Source Note:The provisions of this §52.121 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091.