(a) The department will pay a program provider for ICF/ID Program services provided to individuals enrolled in the ICF/ID Program. Such services include:
  (1) room and board;
  (2) active treatment; and
  (3) medical services.
(b) The department will reimburse a program provider other than a state supported living center, El Paso State Center or the Rio Grande State Center for durable medical equipment in accordance with 1 TAC §355.455 (relating to Payments to Non-State Operated Facilities) and the department's written procedures for durable medical equipment reimbursement.
(c) A program provider must accept the current reimbursement rate or the rate as it may hereafter be amended, as payment in full for ICF/ID Program services provided to an individual enrolled in the ICF/ID Program, and make no additional charge to the individual, any member of the individual's family, or any other source for any item or service including a third party payor, except as allowed by federal or state laws, rules or regulations or the Medicaid State Plan.
(d) If DADS has established the probable existence of a third-party for ICF/ID Program services provided by a non-state operated facility at the time a claim is filed, DADS rejects the claim and returns it to the program provider for a determination of the amount of liability. When the amount of liability is determined, DADS pays the claim to the extent that payment allowed under the HHSC rate payment schedule exceeds the amount of the third party's payment.
(e) If a claim is returned to a program provider for a determination of liability in accordance with subsection (d) of this section, the program provider must:
  (1) submit the claim to the identified third-party for a determination of the amount of liability;
  (2) keep all documentation of actions taken to determine the amount of liability by the third-party; and
  (3) certify to DADS the actions the program provider has taken to determine the liability of the third-party in accordance with instructions from DADS.
(f) To receive payment for ICF/ID Program services, a program provider must:
  (1) prepare and submit a clean claim, as defined in 42 CFR §447.45(b), for such services in accordance with this subchapter and the information available from the state Medicaid claims administrator; and
  (2) submit such a claim within 12 months after the date of service or the date the individual's eligibility is established, whichever is later.
(g) For the purposes of this section, "date of service" is defined as the last day of the month in which the service was provided.
(h) If a program provider submits a claim to a third-party, the requirement to submit the claim to the state Medicaid claims administrator in accordance with subsection (f) of this section is not affected. In addition, the program provider must allow 110 days to elapse after the date the claim was submitted to the third-party before submitting the claim to the state Medicaid claims administrator.
(i) The department will not pay a program provider or will recoup payments made for services provided to an individual:
  (1) if the individual does not meet the eligibility criteria described in §9.236 of this chapter (relating to Eligibility Criteria);
  (2) if enrollment of the individual is not complete, as described in §9.244(l) of this chapter (relating to Applicant Enrollment in the ICF/MR Program);
  (3) if the individual does not have a valid LOC determination;
  (4) if the program provider does not have a signed and dated ID/RC Assessment Form for the individual;
  (5) if the ID/RC Assessment Form electronically transmitted to the department for the individual does not contain information identical to information on the signed ID/RC Assessment Form;
  (6) if the individual is an inpatient of a hospital or nursing facility, is enrolled in a waiver program established under §1915(c) of the Social Security Act, or has elected to receive hospice care in accordance with §30.16 of this title (relating to Election of Hospice Care);
  (7) during a discharge of an individual, including the effective date of discharge as described in §9.227(b) of this chapter (relating to Discharge From a Facility);
  (8) except as provided in this subsection, if the program provider does not have a provider agreement with the department;
  (9) if the program provider does not submit a clean claim for the service in accordance with subsection (f) of this section; or
  (10) if DADS returns a claim to the program provider in accordance with subsection (d) of this section and the program provider:
    (A) does not submit the claim to the identified third party; or
    (B) does not submit the claim to the identified third party in time to be paid in accordance with subsection (h) of this section.
(j) The department may pay a program provider for ICF/ID services up to 30 days after its provider agreement has expired or been terminated if the services were provided to individuals admitted to the facility before the effective date of the expiration or termination and reasonable efforts are being made to move the individuals from the facility.

Source Note: The provisions of this §261.219 adopted to be effective September 1, 2001, 26 TexReg 5384; amended to be effective January 5, 2003, 27 TexReg 12251; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective July 1, 2012, 37 TexReg 4606; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127