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Reporting Year 2024 PERM Review — Medical Record Requests Initiated

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Texas is currently participating in the 2024 reporting year Payment Error Rate Measurement (PERM) review, which began in the spring of 2023. This review includes Texas Medicaid and the Children’s Health Insurance Program (CHIP) claims paid from July 1, 2022, through June 30, 2023.

The Centers for Medicare & Medicaid Services (CMS) initiated PERM to measure the accuracy of Texas Medicaid and CHIP payments. CMS has contracted the Lewin Group and Empower AI to select and review Texas Medicaid and CHIP claims for the programs that are administered by the Texas Health and Human Services Commission (HHSC) and the Texas Department of State Health Services (DSHS).

The Lewin Group has selected claims at random, and Empower AI is currently reviewing the selected claims. State health care program providers must participate in the PERM review and provide medical record documentation that supports the payment made for each claim that is selected for review.

Methods of Provider Notification

If a claim is selected for review, providers receive a series of communications, including the following:

  • A Texas Medicaid & Healthcare Partnership (TMHP) or an HHSC representative will call the provider to verify contact information, such as the provider’s point of contact, mailing address, and fax number.
  • An Empower AI representative will call the provider’s point of contact to ask whether the provider prefers to receive the review notice by fax or through U.S. mail.
  • An Empower AI representative will send the review notice with the selected claims and request copies of the supporting records for each claim.

Deadlines for Providing Requested Medical or Pharmacy Records

Providers must submit the requested information to Empower AI within 75 calendar days of receiving the written request. If Empower AI requests any additional information from the provider, then the provider must submit the requested information to Empower AI within 14 calendar days of receiving the written request.

Important: If a provider fails to respond or produce the complete and correct documentation for a selected claim within the time frame that is indicated in the notice, Empower AI will identify the claim as a PERM exception. In the event of a PERM exception, the provider must reimburse the total amount paid for the claim per state and federal requirements.

Texas Medicaid encourages providers to ask questions about the request for information as soon as possible. This will help prevent a PERM exception for a provider’s failure to respond in a timely manner with complete and accurate information. Providers that have questions about the records request should immediately contact Empower AI customer service representatives at 800-393-3068.

The state’s overall error rate is adversely affected when providers fail to provide the complete documentation in response to PERM requests. Texas Medicaid appreciates all provider support of the PERM process.

Texas Medicaid encourages providers to visit tmhp.com for additional PERM information in future notifications.