2/19/2015

Provider Name

Address

City, State Zip Code

RE: Preliminary Findings of Fact

Dear <Provider Name>:

The Texas Health and Human Services Commission (HHSC) has contracted Health Management Systems, Inc. (HMS) to conduct Medicaid recovery audits on behalf of the state of Texas in accordance with Section 6411 of the Patient Protection and Affordability Care Act of 2010. HMS is authorized to audit provider payments and associated financial records to identify under and over payments and recover any overpayments made to the provider.

HMS has completed a post-payment review of the selected claims and medical records that you submitted. The objective during the review process was to determine if services for which you received payment were provided in conformance with Texas Medicaid policy and were properly reimbursed.

Enclosed is an audit detail report(s), which presents the results of the review as preliminary findings detailing the specific overpayment/underpayment for each claim. The report identifies areas where overpayment/underpayment has been made to you.

If you agree with the findings, you must reimburse the overpayment. Affected claims will be adjusted and the overpayment will be recouped.

If you disagree with the findings, you must notify HMS within 21 calendar days of the date of this letter. You may contact HMS by calling Provider Services at 877-401-3635. If you do not notify HMS of your disagreement, the affected claims will be adjusted and the overpayment will be recouped.

If you disagree with the findings, you can submit any documentation that you feel would support Medicaid payment for these services. All documentation must be received within 21 calendar days of the date of this letter. Please submit your documentation and a copy of this letter to:

HMS-Texas Recovery Audit Services
9275 West Russell Road
Suite 100 - TX
Las Vegas, NV 89148

or
FAX 855-278-3502

The additional documentation will be reviewed, and you will be notified of the outcome.

If, after the additional review, you still disagree with HMS’ audit findings, you may contact HMS with your appeal and the appeal will be forwarded to HHSC for resolution.

If you have questions or need more information, please contact Provider Services at 877-401-3635.

Enclosures