(a) Immediately upon request, the Health and Human
Services Commission, Office of Inspector General (HHSC-OIG), Office
of the Attorney General-Medicaid Fraud Control Unit (OAG-MFCU) and
OAG, Office of the Attorney General-Civil Medicaid Fraud Division
(OAG-CMFD), and the United States Health and Human Services, Office
of Inspector General (HHS-OIG) may review the records of a managed
care organization (MCO) to determine compliance with this subchapter.
(b) Upon receipt of a record review request from any
state or federal agency authorized to conduct compliance, regulatory,
or program integrity functions, an MCO must:
  (1) At no charge to the entities identified in subsection
(a) of this section, provide the records requested by a properly identified
agent of any state or federal agency authorized to conduct compliance,
regulatory, or program integrity functions on the provider, person,
MCO, or the services rendered by the provider or person within 24
hours of the request.
  (2) An exception to the 24 hours stated in paragraph
(1) of this subsection may be made when the OIG or another state or
federal agency representative reasonably believes that the requested
records are about to be altered or destroyed or that the request may
be completed at the time of the request and/or in less than 24 hours.
(c) The request for record review may include but is
not limited to:
  (1) clinical medical or dental patient records;
  (2) other records pertaining to the patient;
  (3) any other records of services provided to CHIP
or other health and human services program recipients and payments
made for those services;
  (4) documents related to diagnosis, treatment, service,
lab results, charting;
  (5) billing records, invoices, documentation of delivery
items, equipment, or supplies;
  (6) radiographs and study models related to orthodontia
services;
  (7) business and accounting records with backup support
documentation;
  (8) statistical documentation;
  (9) computer records and data; and
  (10) contracts with providers and subcontractors.
(d) Failure to produce the records or make the records
available for the purpose of reviewing, examining, and securing custody
of the records may result in HHSC imposing contractual remedies, HHSC-OIG
imposing sanctions against the MCO as described in Chapter 371, Subchapter
G of this title (relating to Legal Action Relating to Providers of
Medical Assistance), or both contractual remedies and sanctions.


Source Note: The provisions of this §370.504 adopted to be effective August 8, 2004, 29 TexReg 7302; amended to be effective March 1, 2012, 37 TexReg 1301