To receive payment for a service, a nursing facility must submit a complete and accurate claim to the state Medicaid claims administrator so that it is received within 12 months after the date of service. In this section, the date of service is the last day of the month in which the service was provided.
  (1) All payments are subject to availability of funds as provided by law.
  (2) For purposes of this section, third party means an individual, entity, or program other than DADS or the program provider that is or may be liable to pay all or part of the expenditures for nursing facility services, including:
    (A) A commercial insurance company offering health or casualty insurance to individuals or groups (including both experience-rated insurance contracts and indemnity contracts);
    (B) A profit or nonprofit prepaid plan offering either medical services or full or partial payment for services; and
    (C) An organization administering health or casualty insurance plans for professional associations, unions, fraternal groups, employer-employee benefit plans, and any similar organization offering these payments or services, including self-insured and self-funded plans.
  (3) If DADS has established the probable existence of a third-party liability for nursing facility services at the time the claim is filed, DADS rejects the claim and returns it to the nursing facility 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.
  (4) If a claim is returned to a nursing facility provider for a determination of liability in accordance with paragraph (3) of this section, the nursing facility must:
    (A) submit the claim to the identified third-party for a determination of the amount of liability;
    (B) keep all documentation of actions taken to determine the amount of liability by the third-party; and
    (C) certify to DADS the actions the nursing facility has taken to determine the liability of the third-party in accordance with instructions from DADS.
  (5) A nursing facility must submit claims and adjustments rejected or denied to the state Medicaid claims administrator within 12 months after the date of service. DADS may pay for claims and adjustments rejected or denied during the 12-month period through no fault of the nursing facility.
  (6) If a nursing facility submits a claim to a third party, the requirement to submit the claim to the state Medicaid claims administrator in accordance with paragraph (5) of this section is not affected. In addition, the nursing facility 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.
  (7) A nursing facility may resubmit a claim after the 12-month period in the case of state-generated retroactive payments.
  (8) The provisions of §19.2413 of this chapter (relating to Determination of Payment Rate Based on the MDS Assessment Submission) apply to this section.
  (9) DADS recoups any inadvertent payments made to a facility.

Source Note: The provisions of this §554.2609 adopted to be effective July 1, 1999, 24 TexReg 4833; amended to be effective November 1, 2002, 27 TexReg 9387; amended to be effective September 3, 2008, 33 TexReg 7264; amended to be effective July 1, 2012, 37 TexReg 4612; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871