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2012 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 3. Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility) : 3.6 Inpatient Utilization Review : 3.6.5 Acknowledgment of Penalty Notice

3.6.5
Hospitals must have on file a signed acknowledgment from the physician stating that the physician received the following notice:
Notice to Physicians: Medicaid payment to hospitals is based, in part, on each client’s principal and secondary diagnoses and the major procedures performed on the client, as attested to by the client’s attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies, or conceals essential information required for payment of federal or state funds, may be subject to fine, imprisonment, or civil penalty under applicable federal and state laws.
The acknowledgment of penalty notice must be specific to Texas Medicaid. Medicare penalty notices are not accepted.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.