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

State will:
2.4 State Responsibilities
a. Participate in established governance process with contractor.
b. Review and approve all provider correspondence communicated and sent to providers
by RAC.
c. Determine and provide to RAC the provider types and dates of service timelines to be
reviewed.
d. Review and approve all audit scenarios or audit concepts proposed by the RAC for
specific provider types approved for review.
e. Provide an extract of claims/encounters for provider types and dates of services
approved for review.
f. Identify claims provided by the RAC with potential improper payments that should be
excluded from the audit because the State or other authorities have already initiated
investigations, collections, reviews, audits, etc.
g. Make claims adjustments by either recouping or repaying improper payments as
identified by the RAC.
h. Provide a report with recoupment or repayment information to the RAC after claims
adjustments requests have been submitted by RAC and processed by HHSC.
i. Work with RAC to compile data of audit activities for required annual CMS reporting.
j. Request medical documentation from contractor for appeals received and will review the
documentation for final determination of improper payment.
k. Provide a monthly report to RAC with final determination information regarding all
appeals received by HHSC.
l. Provide a final reconciliation report at end of audit activity for each provider type that
reflects final recoupment figures and contingency or fixed fee paid (or reimbursement
due to HHSC) to RAC after all adjustments, including any appeals adjustments that have
been made.
m. Monitor contractor’s performance.
2.5 Performance Measures and Associated Remedies
HHSC will monitor the performance of the contract issued under this RFP. All services and
deliverables under the contract will be provided at an acceptable quality level and in a manner
consistent with acceptable industry standard, custom, and practice. Deliverables that are
inaccurate, incomplete or not received in accordance with the timelines contained herein will be
assessed liquidated damages in the amount of $500.00 per calendar day.
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