(RFP) for Recovery Audit Contractor (RAC) - Texas Health and ...

for approval by HHSC to be used in claims identification to submission of claims
adjustment information by the RAC to HHSC for recovery/repayment.
b. Perform analysis of paid claims from Medicaid Management Information Systems
(MMIS) data to determine if services were provided based on federal and state policies
and procedures in effect on the adjudication date for the claim date of service; analysis
includes review of medical documentation to determine if services were medically
necessary.
c. Define each specific improper payment scenario or audit concept to be utilized by the
RAC for each audit type. Each scenario or audit concept must describe the complete
process for identifying incorrect payments and show HHSC the proof of the improper
payment with sufficient detailed supporting information as determined by HHSC and the
specifics regarding the providers, clients and services that the scenario or audit concept
covers.
d. Describe the source authorities utilized to determine the validity of the improper
payments.
e. Present recommendation and impact analysis for each scenario or audit concept to
HHSC subject matter experts (Policy/Operations) and executive management for
approval before pursing identification of improper payments.
f. Conduct medical chart/documentation review.
g. Identify potential improper payments only for service dates and provider types as
determined and approved by HHSC.
h. After consultation with HHSC, develop a process to identify and exclude from audit
review claims reviewed or under review by HHSC OIG, or associated with an audit
already underway (i.e. PERM audit, Federal OIG audit or review, CMS audit or review,
CMS contractor audit or review), or other Federal and State audits or reviews.
i. Once claims have been identified by the RAC with potential improper payments and
approved by HHSC, RAC will utilize current CMS provider abrasion guidelines when
determining and providing to HHSC the timeline for each audit type.
2.3.4. Provider Communication and Support - Claims Based Approach
Obtain HHSC approval of the content for all written and oral communication before commencing
recovery audit(s) and fraud-related audit activities with the Medicaid providers. All
correspondence will be approved by HHSC in advance of use, or when any changes to
approved correspondence is determined necessary.
a. Once the RAC has identified a claim with a potential improper payment, the RAC will
send a letter to the provider requesting medical documentation associated with the
claim. The RAC will follow all HHSC required timelines allowed to providers to respond
to such requests, and must also be able to accept electronic submission of medical
records on CD/DVD or via facsimile at the provider’s request. Upon approval by HHSC,
RAC audits may be conducted either on-site or via desk review, if needed. RAC will
send reminder letters for medical documentation requests, as needed.
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