1 TAC § 371.29. Random Prepayment Review
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Texas Administrative Code › Title 1 ADMINISTRATION › Part 15 TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › 1 TAC § 371.29
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The OIG may perform a random prepayment review of claims submitted by Medicaid providers for reimbursement to determine whether the claim involves fraud, waste, or abuse. Suspect claims identified through this process may result in:
(1) imposition of a recoupment of overpayments and/or other pertinent administrative sanctions or actions;
(2) initiation of a full fraud, waste, or abuse investigation;
(3) referral for criminal or civil investigation and prosecution;
(4) withholding payment of these claims for not more than five working days without notice to the provider for which claims were submitted.
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