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December 2016 Texas Medicaid Provider Procedures Manual

Medical Transportation Program Handbook : 6 Claims Filing : 6.2 Auditing of Claims

6.2
Reimbursement may be recouped when the medical record does not document that the level of service provided accurately matches the level of service claimed. Furthermore, the level of service provided and documented must be medically necessary based on the clinical situation and needs of the patient.
HHSC and TMHP routinely perform retrospective reviews of all providers. HHSC ultimately is responsible for Texas Medicaid utilization review activities. This review includes comparing services billed to the client’s clinical record. The following requirements are general requirements for all providers. Any mandatory requirement not present in the client’s medical record subjects the associated services to recoupment.

Texas Medicaid & Healthcare Partnership
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