(a) DADS pays a contractor for a claim for services
that meets the requirements described in subsection (b) of this section.

(b) A contractor must ensure a claim for services is:
  (1) for a service that has been provided by a contractor;

  (2) a clean claim;
  (3) complete and accurate;
  (4) submitted within 12 months after one of the following,
whichever is later:
    (A) the last day of the month in which the service
was provided, the adaptive aid or medical supply delivered, or the
minor home modification completed; or
    (B) the date the individual's eligibility for the service
was determined;
  (5) for a type and amount of service that is authorized
by DADS;
  (6) for a service provided to an individual who is
eligible for the service;
  (7) except as provided in DADS rules governing services
provided under the contract, for a service provided to an individual
whose authorization for services has not been suspended or terminated
by DADS;
  (8) for a service provided during a time period authorized
by DADS;
  (9) for a service provided during the term of, and
in accordance with, the contract, this subchapter, and DADS rules
governing services provided under the contract;
  (10) supported by records required by the contract
and DADS rules governing services provided under the contract;
  (11) for a service provided by a qualified service
provider in accordance with DADS rules governing services provided
under the contract;
  (12) for a service ordered by a qualified practitioner,
if required by the contract or DADS rules governing services provided
under the contract;
  (13) submitted in accordance with procedures required
by DADS rules governing services provided under the contract and by
the claims administrator; and
  (14) not for a service that a source other than DADS
would have paid for if the contractor had submitted a proper, complete,
and timely request for payment to the other source.
(c) As used in subsection (b)(11) and (12) of this
section, the terms "qualified service provider" and "qualified practitioner"
do not include a person whose health-related license has been suspended
or revoked or who has been excluded from participation in a program
administered under Title V, XVIII, XIX, or XX of the Social Security
Act.
(d) DADS denies a claim for services that does not
meet the requirements in subsection (b) of this section and DADS rules
governing services provided under the contract. If DADS denies a claim
for services, a contractor may request and receive an administrative
hearing.
(e) If a contractor or DADS determines that the contractor
received payment for a claim for services that does not meet the requirements
in subsection (b) of this section and DADS rules governing services
provided under the contract:
  (1) the contractor may submit a corrected claim for
services to allow DADS to adjust amounts paid to a contractor, even
if it is after the 12-month period described in subsection (b)(4)
of this section; or
  (2) DADS recoups funds paid to the contractor in accordance
with §49.533 of this chapter (relating to Recoupment).
(f) If a claim for services is denied by DADS, the
contractor that submitted the claim may submit a corrected claim within
the 12-month period described in subsection (b)(4) of this section.
(g) DADS may adjust amounts paid to a contractor after
the 12-month period described in subsection (b)(4) of this section.


Source Note: The provisions of this §49.311 adopted to be effective September 1, 2014, 39 TexReg 6637