(a) HHSC pays a service provider agency for independent living skills training, day habilitation, employment assistance, supported employment, and behavioral support in accordance with the fee-for-service rate for the specific service, which can be found on the HHSC website.

(b) To be paid for the provision of a service, the service provider agency must submit a service claim that meets the requirements in 40 TAC §49.311 (relating to Claims Payment) and the IDD Habilitative Specialized Services Billing Guidelines.

(c) If a designated resident's IHSS are suspended or terminated, the service provider agency must not submit a claim for services provided during the period of the designated resident's suspension or after the termination, except that the service provider agency may submit a claim for the first day of the designated resident's suspension or termination.

(d) HHSC does not pay the service provider agency for a service if:

(1) the service is provided for a designated resident when there is not a signed, dated, and authorized plan of care for the designated resident; or

(2) the designated resident is ineligible for Medicaid benefits at the time the service is provided.

(e) HHSC recoups any payments made to the service provider agency for a service, if:

(1) the service is not provided in accordance with: (A) a signed, dated, and authorized plan of care meeting the requirements set forth in §368.301 of this chapter (relating to Plan of Care); (B) the designated resident's HSP; (C) the designated resident's implementation plan; or (D) the IDD Habilitative Specialized Services Billing Guidelines;

(2) the service is not documented in accordance with Texas Medicaid Provider's Procedures Manual found on the TMHP website and the IDD Habilitative Specialized Services Billing Guidelines;

(3) the claim for the service does not meet the requirements in 40 TAC §49.311 or the IDD Habilitative Specialized Services Billing Guidelines;

(4) HHSC determines that the service would have been paid for by another source if the service provider agency had submitted to the other source a proper, complete, and timely request for payment for the service;

(5) the payment was for employment assistance or supported employment and the service provider agency does not ensure or maintain documentation in the designed resident's record that the service is not available for the designated resident through a program funded by the Rehabilitation Act of 1973;

(6) the service is provided by an individual service provider who does not meet the qualifications to provide the service as described in §368.406 of this chapter (relating to Provider Qualifications) and the IDD Habilitative Specialized Services Billing Guidelines; or

(7) the service is not provided.

(f) The service provider agency must refund to HHSC any overpayment made to the service provider agency within 60 days after the service provider agency's discovery of the overpayment.

Source Note: The provisions of this §368.701 adopted to be effective September 1, 2021, 46 TexReg 4151