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

timeline will include reasonable and sufficient time for the RAC to complete the entire
audit process and resolve issues, including completion of appeals associated with the
audit and collection of improper payments to providers.
c. Exhibit the ability to show and ensure appeal rates, as well as appeal overturn rates, will
be kept at a minimum. If at any time during the course of the contract period, appeal
rates for a specific provider type/audit concept exceed HHSC expectations, the RAC will
be required to submit an action plan to HHSC detailing actions the RAC will take to
reduce appeal rates for future review.
d. Providers have the right to appeal recoupments through existing HHSC appeal
procedure processes for HHSC paid claims, pursuant to 1 Tex. Admin. Code §354.2217
(relating to Provider Appeals and Reviews) or 1 Tex. Admin. Code §371.1709 (relating to
Recoupment of Overpayments Pursuant to Audit) depending on contract type; for HHS
agency (DADS, DSHS, DARS) paid claims, appeals processes in place for those
agencies may also be applicable; all required timelines for the appeal processes in place
at HHSC will be followed.
e. Upon request by HHSC, the RAC will provide copies of all medical documentation on file
for any appeal received by HHSC within 21 days of request date.
f. HHSC’s decision on any provider appeal is the final decision and the case will be
considered closed. Additionally, there is no further avenue for the RAC to appeal the
final decision made by HHSC.
g. The RAC must participate in formal hearings/appeals and provide expert testimony, as
needed, and be available to review testimony and evidence with HHSC legal counsel at
least two days in advance of any scheduled testimony. HHSC explicitly maintains a right
of access to RAC working papers (including copies of documentation collected from the
provider and all chain of custody and authenticating affidavits related to the working
papers and all underlying records and documents) and requires that evidence collected
(including expert opinions) be obtained in accordance with Texas law, including the
Texas Rules of Evidence.
2.3.8. Key Personnel and Staffing
Key personnel are those identified below. These are persons essential to the successful
performance under the RFP and contract. HHSC reserves the right to add key personnel
positions within individual assignments or audits, as necessary for the appropriate performance
of the work. The educational requirements are only required, if specified below.
Provided below are skill sets considered essential in the performance of this contract:
a. Project Director: Individual with relevant experience in managing a complex system or
project for at least 5 years.
b. Medical Director: Individual licensed to practice medicine in the State of Texas is
required; must have relevant Medicaid experience in the health insurance industry, with
a utilization review firm or a health care claims processing organization in a role that
involved developing coverage or medical necessity policies and guidelines. Education
(Required): The Medical Director shall be a Doctor of Medicine or Doctor of Osteopathy
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