Texas Health and Human Services Commission and Office of Inspector General v. Antoine Dental Center

ACCEPTED
06-15-00076-CV
SIXTH COURT OF APPEALS
TEXARKANA, TEXAS
11/9/2015 4:47:09 PM
DEBBIE AUTREY
CLERK
No. 06-15-00076-CV
FILED IN
In the Court of Appeals for the 6th COURT OF APPEALS
Sixth Judicial District TEXARKANA, TEXAS
11/10/2015 8:06:00 AM
Texarkana, Texas
DEBBIE AUTREY
Clerk
Texas Health and Human Services Commission, AND
Office of Inspector General,
Appellants,
v.
Antoine Dental Center,
Appellee.
th
On Appeal from the 200 Judicial District Court of Travis County, Texas
Cause No. D-1-GN-14-002229
Hon. Amy Clark Meachum, Presiding
BRIEF OF APPELLANTS
Respectfully submitted, RAYMOND CHARLES WINTER
State Bar No. 21791950
Office of the Attorney General Chief, Civil Medicaid Fraud Division
CHARLES E. ROY REYNOLDS B. BRISSENDEN
First Assistant Attorney General State Bar No. 24056969
JAMES E. DAVIS NOAH REINSTEIN
Deputy Attorney General for Civil State Bar No. 24089769
Litigation
Assistant Attorneys General
Office of the Texas Attorney General
P.O. Box 12548, Capitol Station MC 056-1
Austin, Texas 78711-2548
Telephone: (512) 936-1709
Facsimile: (512) 370-9477
Raymond.Winter@texasattorneygeneral.gov
Attorneys for Texas Health and Human
Services Commission and Office of Inspector
General
Submitted: November 9, 2015 ORAL ARGUMENT REQUESTED
IDENTITY OF PARTIES AND COUNSEL
Pursuant to Tex. R. App. P. 38.1(a), appellant presents the following list of all
parties and names and addresses of counsel:
Appellant/Defendant at District Court: Texas Health and Human Services
Commission and Office of Inspector
General
Counsel:
Raymond C. Winter
Reynolds B. Brissenden
Noah Reinstein
Office of the Texas Attorney General
P.O. Box 12548
Austin, Texas 78711-2548
Telephone: (512) 936-1709
Facsimile: (512) 370-9477
Appellee/Plaintiff at District Court: Antoine Dental Center
Counsel: Jason Ray
Riggs & Ray, PC
506 W. 14th Street, Suite A
Austin, Texas 78701
Telephone: (512) 457-9812
Facsimile: (512) 457-9066
ii
TABLE OF CONTENTS
IDENTITY OF PARTIES AND COUNSEL ...................................................... ii
TABLE OF CONTENTS ..................................................................................... iii
INDEX OF AUTHORITIES ............................................................................... vi
STATEMENT OF THE CASE .............................................................................2
STATEMENT REGARDING ORAL ARGUMENT .........................................3
ISSUES PRESENTED ...........................................................................................3
STATEMENT OF FACTS ....................................................................................4
I. The Texas Medicaid program provides health care for the indigent,
including limited orthodontia services..................................................4
A. Medicaid provides a limited benefit for orthodontics. ........................4
B. Providers must obtain prior authorization by accurately and
honestly representing that their patient has a severe handicapping
malocclusion before they may request reimbursement for
orthodontic services. ...............................................................................6
1. Providers are required to rely on their education and
training in making diagnoses, requesting prior authorization,
and making claims for Medicaid reimbursement. ...................7
2. “Ectopic eruption” is an exceedingly rare condition, and in
the TMPPM the term is afforded the meaning generally
understood in the practice of dentistry. ....................................8
II. HHSC-OIG is responsible for protecting Medicaid from waste,
fraud and abuse. OIG is required by law to impose a payment hold
based on a credible allegation that a provider has committed
Medicaid fraud. .....................................................................................10
III. Antoine billed Texas Medicaid for more than $8 million in
orthodontia services over a three-year period, and OIG placed
Antoine on payment hold. ....................................................................14
IV. Antoine requested a hearing on the payment hold, and, after the
iii
hearing and the ALJs’ recommendation that HHSC order OIG to
lift the hold, the EC reversed the PFD and ordered the hold to
remain in place. .....................................................................................19
STANDARD OF REVIEW .................................................................................21
SUMMARY OF THE ARGUMENT ..................................................................24
ARGUMENT ........................................................................................................25
I. The EC acted within his discretion to correct misapplications of
Medicaid law and policy by the SOAH ALJs. ...................................25
A. The proper interpretation of Texas Medicaid policy is a
question of law to be determined by the EC. The EC
properly interpreted Medicaid policy in harmony with the
governing statutes and regulations, and Antoine has shown
no basis for the Court to deviate from the EC’s correct
interpretation. ............................................................................27
B. The EC’s corrections of the ALJs’ errors in interpreting
Medicaid policy are entitled to respect from the Court. .......29
II. The EC did not exceed his authority in entering the AFO and
Antoine cannot establish otherwise.....................................................32
A. The ALJs misunderstood and misapplied Texas Medicaid
law and policy and the EC corrected the misunderstanding
with a proper construction of law and policy. ........................33
1. The rules of statutory construction govern questions of
agency policy and administrative rules. ..............................37
2. The ALJs ignored statutes, rules, and evidence and made
fundamental errors in interpreting and applying Texas
Medicaid policy. The misapplications were properly
corrected by the EC. .............................................................38
B. Substantial evidence exists to show that Antoine committed
fraud or made willful misrepresentations necessary to
maintain the payment hold. The EC properly corrected the
ALJs’ errors, and Antoine cannot establish that the EC
exceeded his authority. .............................................................43
1. Providers have a duty to know and follow law and policy.
iv
.................................................................................................44
2. Dr. Kanaan’s scoring pattern shows, at a minimum, he
acted with conscious disregard or reckless indifference to
the truth or falsity of his representations of patient
conditions. ..............................................................................45
3. The ALJs compounded their errors by relying on
“experts” who misunderstood and misapplied Texas
Medicaid policy......................................................................47
III. Every modification made in the EC’s AFO is supported by
substantial evidence and Antoine cannot establish otherwise..........49
A. Finding of Fact No. 45...............................................................49
B. Finding of Fact No. 46...............................................................51
C. Finding of Fact No. 47...............................................................52
D. Finding of Fact No. 48...............................................................54
E. Finding of Fact No. 49...............................................................56
F. Finding of Fact No. 50...............................................................57
G. Conclusion of Law No. 13. ........................................................58
CERTIFICATE OF COMPLIANCE .................................................................61
CERTIFICATE OF SERVICE ...........................................................................61
INDEX OF APPENDIX .......................................................................................62
v
INDEX OF AUTHORITIES
Cases
Akin v. Tex. State Bd. of Dental Exam’rs, No. 03-14-00390-CV, 2015 WL1611803,
(Tex. App.—Austin Apr. 9, 2015, no pet.hist.).........................24, 25, 26, 28, 43, 59
Atascosa Cnty. v. Atascosa Cnty. Appraisal Dist., 990 S.W.2d 255 (Tex.1999)...29
Bd. of Law Exam’rs v. Stevens, 868 S.W.2d 773 (Tex. 1994), cert. denied, Stevens
v. Bd. of Law Exam’rs, 512 U.S. 1206, 114 S. Ct. 2676 (1994)…………...............22
Bd. of Trs. of the Emps. Ret. Sys. v. Benge, 942 S.W.2d 742 (Tex. App.—Austin
1997, writ denied)....................................................................................................22
Boswell v. Brazos Electric Power, 910 S.W.2d 593 (Tex. App.—Fort Worth 1995,
writ denied)........................................................................................................37, 42
Bridgestone/Firestone, Inc. v. Glyn-Jones, 878 S.W.2d 132 (Tex.1994)…….38, 40
City of El Paso v. Pub. Util. Comm’n, 883 S.W.2d 179 (Tex. 1994)..........22, 23, 32
City of Waco v. Tex. Comm’n Envtl. Quality, 346 S.W.3d 781(Tex. App. —Austin
2011, rev’d on other grounds 413 S.W.3d 409 (Tex. 2013))…..............................32
Cont’l Cas. Ins. Co. v. Functional Restoration Assocs.,19 S.W.3d 393 (Tex.
2000)........................................................................................................................37
Employees Ret. Sys. of Texas v. Garcia, 454 S.W.3d 121 (Tex. App.—Austin
2014), pet. denied (Sept. 4, 2015)………………...…….......…………………21, 32
Exxon Corp. v. R.R. Comm'n, 993 S.W.2d 704 (Tex. App.—Austin 1999, no
pet.)..........................................................................................................................27
Fitzgerald v. Advanced Spine Fixation Sys., Inc.,996 S.W.2d 864 (Tex. 1999).....37
Flores v. Emps. Ret. Sys. of Tex., 74 S.W.3d 532 (Tex. App.—Austin 2002, pet.
denied).....................................................................................................................49
Froemming v. Tex. State Bd. of Dental Exam’rs, 380 S.W.3d 787 (Tex. App.—
Austin 2012, no pet.)...................................................................................24, 26, 28
vi
Gomez v. Tex. Educ. Agency, 354 S.W.3d 905 (Tex. App.—Austin 2011, pet.
denied).....................................................................................................................29
Graff Chevrolet Co. v. Tex. Motor Vehicle Bd., 60 S.W.3d 154 (Tex. App.—Austin
2001, pet. denied).........................................................................................22-23, 24
Granek v. Texas State Bd. of Med. Exam'rs, 172 S.W.3d 761 (Tex. App.—Austin
2005, no pet.)...........................................................................................................59
Gulf States Utils. Co. v. Pub. Util. Comm’n,841 S.W.2d 459 (Tex. App.—Austin
1992, writ denied)....................................................................................................22
Harlingen Family Dentistry v. Tex. Health & Human Servs. Comm’n, 452 S.W.3d
479 (Tex. App.—Austin 2014, pet. filed)................................................................18
Heckler v. Community Health Servs., 467 U.S. 51(1984)..................................43-44
Heritage on the San Gabriel v. Tex. Comm’n on Envt’l Quality, 393S.W.3d
417(Tex. App.—Austin 2012, pet. denied).......................................................32, 49
In re: E.I. DuPont de Nemours & Co., 136 S.W.3d 218 (Tex. 2004).....................13
Levy v. Tex. State Bd. of Medical Exam’rs, 966 S.W.2d 813 (Tex. App.–Austin
1998, no pet.)...........................................................................................................49
Lewis v. Southmore Savings Ass’n, 480 S.W.2d 180 (Tex. 1972)...........................23
Liberty Mut. Ins. Co. v. Garrison Contractors, Inc., 966 S.W.2d 482
(Tex. 1998)……...……………………………………………………………...... 37
Locklear v. Tex. Dep’t of Ins., 30 S.W.3d 595 (Tex. App.—Austin 2000, no
pet.)………………………………………………………………………………..23
N. Mem’l Med. Ctr. v. Gomez, 59 F.3d 735 (8th Cir. 1995)...................................45
Personal Care Products, Inc. v. Hawkins, 635 F.3d 155 (5th Cir. 2001)..............44
Pierce v. Tex. Racing Comm’n, 212 S.W.3d 745 (Tex. App.—Austin 2006, pet.
denied)…………………………....... …………………………...……………49, 59
R.R. Comm’n of Tex. v. Tex. Citizens for a Safe Future & Clean Water, 336 S.W.
3d 619 (Tex. 2011)…..…................................................................28, 29, 32, 37, 38
vii
Rehak Creative Servs. v. Witt, 404 S.W.3d 716 (Tex. App.—Houston [l4th Dist.]
2013, pet. denied)....................................................................................................55
Sanchez v. Tex. State Bd. of Med. Exam’rs, 229 S.W.3d 498 (Tex. App.—Austin
2007, no pet.)...............................................................................................24, 27, 50
Smith v. Montemayor, 03-02-00466-CV, 2003 WL 21401591 (Tex. App.—Austin
June 19, 2003, no pet.)...........................................................................26, 27, 28, 50
State v. Pub. Util. Comm’n, 883 S.W.2d 190(Tex. 1994)...........................21, 22, 32
State v. Terrell, 588 S.W.2d 784 (Tex.1979).....................................................37-38
State v. Mid-South Pavers, Inc., 246 S.W.3d 711(Tex. App.–Austin 2007, pet.
denied).....................................................................................................................49
Sw. Pharm. Solutions, Inc., v. Tex. Health & Human Servs. Comm’n, 408 S.W.3d
549 (Tex. App.—Austin 2013, pet. denied).........................28, 29, 30-31, 32, 42, 48
Tex. Ass’n of Psychological Assocs. v. Tex. State Bd. of Exam’rs of Psychologists,
439 S.W.3d 597602 (Tex. App.—Austin 2014, no pet.).........................................23
Tex. Emp’t Comm’n v. Hays, 360 S.W.2d 525 (Tex. 1962)...............................21-22
Tex. Health Facilities Comm’n. v. Charter Med.-Dallas, Inc., 665 S.W.2d 446
(Tex.1984)...............................................................................................................21
Tex. State Bd. of Med. Exam’rs v. Birenbaum, 891 S.W.2d 333 (Tex. App.—Austin
1995, writ denied)....................................................................................................22
Tex. State Bd. of Med. Exam’rs v. Dunn, 03-03-00180-CV, 2003 WL 22721659
(Tex. App.—Austin Nov. 20, 2003, no pet.)..........................................26-27, 49, 50
Tex. State Bd. of Dental Exam’rs v. Sizemore, 759 S.W.2d 114 (Tex. 1988).........22
Tex. Tech Univ. Health Scis. Ctr. v. Apodaca, 876 S.W.2d 402 (Tex. App.—El
Paso 1994, writ denied)...........................................................................................13
TGS-NOPEC Geophysical Co. v. Combs, 340 S.W.3d 432 (Tex. 2011)…............40
United States v. Carbajal, 290 F.3d 277 (5th Cir. 2002)........................................12
viii
United States v. Floyd, 343 F.3d 363 (3d Cir. 2003)...............................................12
Wood v. Tex. Comm’n Envtl. Quality, No. 13-13-00189-CV, 2015 WL 1089492
(Tex. App.—Corpus Christi, Mar. 5, 2015, no pet.).........................................26, 48
Zimmer US, Inc. v. Combs, 368 S.W.3d 579 (Tex. App.—Austin 2012, no pet)....30
Federal Regulations/Statutes
42 C.F.R. § 455.2...............................................................................................12, 46
42 C.F.R. § 455.23.............................................................................2, 11, 12, 18, 58
42 C.F.R. § 455.23(a)(1)....................................................................................11-12
42 U.S.C. §1395........................................................................................................4
42 U.S.C. §1396..................................................................................................4, 11
State Regulations
1 Tex. Admin. Code § 155.507(c)(1)......................................................................19
1 Tex. Admin. Code § 357.483(a)(1)-(2)................................................................20
1 Tex. Admin. Code § 357.488(b)...........................................................................20
1 Tex. Admin. Code § 357.497...............................................................................19
1 Tex. Admin. Code § 357.497(e)...........................................................................20
1 Tex. Admin. Code § 371.1...................................................................................10
1 Tex. Admin. Code § 371.1605.............................................................................11
1 Tex. Admin. Code § 371.1617(a)(1)(A)-(C)........................................................58
1 Tex. Admin. Code § 371.1617(a)(3)....................................................................20
1 Tex. Admin. Code § 371.1617(5)(B)...................................................................11
1 Tex. Admin. Code § 371.1617(1)(A)...................................................................18
1 Tex. Admin. Code § 371.1617(1)(B)...................................................................18
1 Tex. Admin. Code § 371.1617(1)(I).....................................................................18
1 Tex. Admin. Code § 371.1617(1)(K)...................................................................18
1 Tex. Admin. Code § 371.1617(2)(A)...................................................................18
1 Tex. Admin. Code § 371.1703(b)(3)....................................................................58
25 Tex. Admin. Code § 33.71....................................................4-5, 6, 34, 36, 39, 41
State Statutes
Tex. Gov’t Code § 311.002(4).................................................................................37
Tex. Gov’t Code § 311.011(a)...........................................................................38, 39
Tex. Gov’t Code § 311.011(b)...........................................................................38, 41
Tex. Gov’t Code § 311.021(2) ......................................................................... 38, 41
ix
Tex. Gov’t Code § 311.021(3)...........................................................................38, 41
Tex. Gov’t Code § 311.021(4)...........................................................................38, 41
Tex. Gov’t Code § 311.021(5)...........................................................................38, 41
Tex. Gov’t Code § 311.023(1)...........................................................................38, 41
Tex. Gov’t Code § 311.023(5)...........................................................................38, 41
Tex. Gov’t Code § 311.023(6).....................................................................29, 38, 41
Tex. Gov’t Code § 312.005.....................................................................................37
Tex. Gov’t Code § 531.001................................................................................10-11
Tex. Gov’t Code § 531.0055(b)(1)............................................................................4
Tex. Gov’t Code § 531.1011(1)...............................................................................12
Tex. Gov’t Code § 531.102.....................................................................................10
Tex. Gov’t Code § 531.102(a).................................................................................18
Tex. Gov’t Code § 531.102(g).................................................................................58
Tex. Gov’t Code § 531.102(g)(2)............................................................2, 11, 18, 47
Tex. Gov’t Code § 2001.058(e)...................................................................26, 27, 59
Tex. Gov’t Code § 2001.058(e)(1)....................................................................24, 26
Tex. Gov’t Code § 2001.062(b)...............................................................................19
Tex. Gov’t Code § 2001.174...................................................................................21
Tex. Gov’t Code § 2001.174(1)...............................................................................21
Tex. Gov’t Code § 2001.174(2)...............................................................................23
Tex. Gov’t Code § 2001.175(e)...............................................................................21
Tex. Hum. Res. Code § 32.0291(b).............................................................13, 18, 19
Tex. Hum. Res. Code § 32.0291(c).....................................................................2, 13
Tex. Hum. Res. Code § 32.032(b)(1)......................................................................10
Tex. Hum. Res. Code § 32.091(c)...........................................................................58
Tex. Hum. Res. Code § 36.0011(a).......................................................11, 53, 55, 56
Tex. Hum. Res. Code § 36.0011(b)...................................................................53, 56
Secondary Sources
F. Scott McCown & Monica Leo, When Can an Agency Change the Findings of
Conclusions of an ALJ?: Part Two, 51 Baylor L. Rev. 63, 69-70
(1999)………………………………………………...……….……….26, 27, 50
x
No. 06-15-00076-CV
In the Court of Appeals for the Sixth Judicial District
Texarkana, Texas
Texas Health and Human Services Commission, AND
Office of Inspector General,
Appellants,
v.
Antoine Dental Center,
Appellee.
th
On Appeal from the 200 Judicial District Court of Travis County, Texas
Cause No. D-1-GN-14-002229
Hon. Amy Clark Meachum, Presiding
TO THE HONORABLE SIXTH COURT OF APPEALS:
The Texas Health and Human Services Commission (“HHSC”), and the Office
of Inspector General (“OIG”) (collectively “State”) respectfully request that this
Court reverse the district court’s decision, which reversed HHSC’s entry of an
Amended Final Order (“AFO”) sustaining a payment hold against Antoine Dental
Center (“Antoine”) for violations of Texas law and regulations related to the
Medicaid program.
HHSC Executive Commissioner Dr. Kyle Janek (“EC”) acted within his
authority in entering the AFO, which is supported by substantial evidence. The
district court erred in reaching its decision that the AFO should be reversed because
the AFO is reasonably supported by substantial evidence and because the EC acted
1
within its statutory authority in entering the AFO. At the district court, Antoine
failed to meet its burden to show otherwise. Therefore, the AFO should be affirmed
by this Court.
STATEMENT OF THE CASE
The EC, on behalf of HHSC, issued the AFO, affirming a payment hold
imposed by HHSC-OIG on Antoine. Tex Hum. Res. Code § 32.0291(c); Tex.
Gov’t Code § 531.102(g)(2); 42 C.F.R. § 455.23. See Appendix A, HHSC’s
AFO, dated May 2, 2014 (copy also at A.R. 1743-85).1 Antoine filed a suit for
judicial review appealing the AFO. The district court reversed the AFO without
giving any explanation for its reversal. Aggrieved by the district court order, the
State timely filed this appeal.
1
The pleadings and copies of the hearing transcript, contained within HHSC’s
Administrative Record (“A.R.”), are labeled with the Bates prefix “00001” through “2795.” The
A.R. was admitted as Exhibits 1 and 2 in the district court and is part of the clerk’s record.
2
STATEMENT REGARDING ORAL ARGUMENT
Pursuant to Tex. R. App. P. 38.1(e), the State respectfully requests oral
argument. Antoine’s position, if accepted, would severely undermine the State’s
efforts to punish and deter fraud in the Medicaid program, which comprises a quarter
of the State’s budget. An adverse decision would likely impede the State’s efforts
to enforce numerous other public-welfare statutes that expressly authorize the State
to sue wrongdoers in the health and medical fields. The State believes that oral
argument will assist the Court’s decisional process; and the importance of the matter
and the intricacies of the relevant statutes and Medicaid policies warrant oral
argument.
ISSUES PRESENTED
I. The EC acted within his discretion to correct misapplications of Medicaid
law and policy by the SOAH ALJs.
II. The EC did not exceed his authority in entering the AFO and Antoine
cannot establish otherwise.
III. Every modification made in the EC’s AFO is supported by substantial
evidence and Antoine cannot establish otherwise.
3
STATEMENT OF FACTS
I. The Texas Medicaid program provides health care for the
indigent, including limited orthodontia services.
The federal government enacted the Medicaid program in 1965 to help the
states provide healthcare for the indigent. Medicaid is funded jointly by federal and
state government, as mandated by federal law. 42 U.S.C. § 1396. In Texas, the
agency responsible for administering Medicaid is HHSC. Tex. Gov’t Code §
531.0055(b)(1).2
A. Medicaid provides a limited benefit for orthodontics.
Texas Medicaid provides coverage for orthodontic services to qualifying
children on a very limited basis. 3 The law restricts when Texas Medicaid will pay
for orthodontic services:
Orthodontic services for cosmetic reasons only are not a
covered Medicaid service. Orthodontic services must be prior
authorized and are limited to treatment of severe
handicapping malocclusion and other related conditions as
described and measured by the procedures and standards
published in the TMPPM [(“Texas Medicaid Provider
Procedures Manual”)].
2
Currently more than 4.5 million Texans are enrolled in Medicaid. See
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/texas.html, Appendix
B. In 2013, Medicaid comprised about 26.2 percent of the Texas state budget, amounting to
approximately $25.6 billion dollars. See Pink Book, 1-1, Appendix C.
3
HHSC administers the Medicaid program pursuant to Texas’s “Medicaid state plan.” The state
plan, is reviewed and approved by the federal Centers for Medicare & Medicaid Services. Tex.
Gov’t Code § 531.097.
4
25 Tex. Admin. Code § 33.71 (emphasis added). Since 2003, the Texas Medicaid
orthodontia benefit policy has covered orthodontic services under limited scenarios.
Relevant to this matter is coverage for children between the ages of 12 and 20 who
have dysfunction and a severe handicapping malocclusion which is defined by an
accurate and honest Handicapping Labio-lingual Deviation (“HLD”) score of 26
points or greater. Texas Medicaid does not pay, nor has it ever paid, for cosmetic
orthodontics. See, e.g., TMPPM (2011) (Ex. R-17), Vol. 2, § 4.2.24, copy at
Appendix D; TMPPM (2010) (Ex. R-16),Vol. 2, § 5.3.24 (same), copy at
Appendix E; TMPPM (2009), Vol. 2, § 19.19 (Ex. R-15) (same), copy at
Appendix F; 4 TMPPM (2008), Vol. 2 § 19.18 (Ex. R-14), copy at Appendix G.
See also 25 Tex. Admin. Code § 33.71 (same). In all qualifying cases,
comprehensive orthodontic treatment (i.e. “full banding” or “full braces,”) is only
available for children twelve years of age to twenty (at the time of prior
authorization) who have lost their baby teeth. See Ex. R-15 at § 19.19.6; App. F.
4
The TMPPM states:
19.19 Orthodontic Services (THSteps): Orthodontic services for cosmetic purposes only are not
a benefit of Texas Medicaid. Orthodontic services are limited to the treatment of children who
are 12 years of age and older with severe handicapping malocclusion…
19.19.1 Benefits and Limitations: Orthodontic services include the following: Correction of
severe handicapping malocclusion as measured on the Handicapping Labiolingual Deviation
(HLD) Index…A minimum score of 26 points is required for full banding approval (only
permanent dentition cases are considered)…
Orthodontic services for cosmetic purposes only are not a benefit of Texas Medicaid or THSteps.
5
B. Providers must obtain prior authorization by accurately and
honestly representing that their patient has a severe
handicapping malocclusion before they may request
reimbursement for orthodontic services.
Providers must submit a prior authorization request, and receive approval,
before seeking reimbursement for orthodontic services. See 25 Tex. Admin. Code §
33.71; see also Ex. R-15 at § 19.19.2; App. F. “Prior authorization is a condition for
reimbursement; it is not a guarantee of payment.” Id. Providers are required to
submit truthful and complete information when seeking prior authorization.5
The prior authorization application includes the provider’s certification that a
child has a severe handicapping malocclusion and the treatment is necessary to
correct it. To support a finding that a child has a severe handicapping malocclusion,
a provider must, inter alia, submit an HLD scoresheet accurately evaluating the
patient. See Ex. R-15 at § 19.19.2 (2009); App. F. A prior authorization request is
generally approved if the child has a severe handicapping malocclusion, as indicated
by an honest score of 26 or more on the HLD. See id. 6
5
Specifically, providers are required to submit:
• An orthodontic treatment plan, which “should incorporate only the minimal number of
appliances required to properly treat the case”;
• “[c]ephalometric radiograph with tracing models”;
• “[c]ompleted and scored HLD score sheet with diagnosis of Angle class (26 points
required for approval of non-cleft palate cases.”);
• Facial photographs;
• Full series of radiographs or a panoramic radiograph; diagnostic films are required.
Id., at App. F.
6
For a patient for whom the provider scores less than 26, the provider may submit a written
narrative to qualify for benefits. This did not occur with the patients in this case
6
1. Providers are required to rely on their education and
training in making diagnoses, requesting prior
authorization, and making claims for Medicaid
reimbursement.
The HLD allows providers to score nine specific dental conditions in a
patient’s mouth. The conditions identified on the HLD scoresheet are conditions that
are generally recognized in dentistry, including but not limited to: ectopic eruption,
cleft palate, overjet, overbite, and mandibular protrusion (“underbite”). The
condition most relevant in this case is ectopic eruption.
The TMPPM instructs providers how to score using the HLD scoresheet. The
instructions include a description of ectopic eruption. See, e.g., Ex. R-15 at § 19.21
(2009), at App. F. The TMPPM does not define ectopic eruption for the purposes
Texas Medicaid. HHSC’s policy expert Dr. Altenhoff testified that the terms in the
ectopic eruption instruction are not defined, but, rather, are accorded their plain and
ordinary meaning in the English language. Vol. 1 at 103:8-12, A.R. at 1914; see also
R-88, Proffer of Rebuttal Testimony from Dr. Linda Altenhoff (Medicaid did not
intend, at any time, for the term “‘ectopic eruption’ to have a different meaning when
used in the evaluation of Medicaid patients than is generally understood in the
practice of dentistry” and “dentists [were] expected to employ the training and
education they received as dentists in applying the terms used in the Provider
Manual”), Appendix J; and Vol. 3 at 241:5-11 (where Deputy Inspector General for
Enforcement testified to the same proposition), A.R. at 2528.
7
2. “Ectopic eruption” is an exceedingly rare condition, and
in the TMPPM the term is afforded the meaning
generally understood in the practice of dentistry.
“Ectopic eruption” is a rare dental condition – occurring in only 1.5 to 9
percent of the population 7 – primarily affecting the first molars, upper and lower
canines.8 Scientific literature describes the low frequency of ectopic eruption
occurring even once per patient. See R-51, (ectopic eruption only occurring in 1.5-
1.6% of a sample population), at App. H. The frequency of the same rare condition
occurring multiple times and/or bilaterally in the same patient is “infinitesimally
smaller.” 9 The chance of 100% of the patients in a sample having not only one
instance of a rare condition, but always at least 6 instances, and always two or more
bilateral instances, is “zero. It’s not possible.” 10
OIG’s orthodontic expert, Dr. Larry Tadlock, described that ectopic eruption,
as explained in Dr. William Proffit’s textbook Contemporary Orthodontics, means
a tooth that erupts in the wrong place.11 The Proffit textbook, a leading orthodontic
textbook, explains that ectopic eruption is caused by malposition of a permanent
7
Vol. 1 at 173:3-6, A.R. at 1984; see also R-51 at 8 (Thilander article describing ectopic eruption
as an “anomaly” occurring in only 1.5-1.6% of a sample population of 4724 patients), Appendix
H.
8
Vol. 1 at 153:22-24, A.R. at 1964.
9
Vol. 1 at 174:16-17, A.R. at 1985.
10
Id. at 174:1, A.R. at 1985; R-49, Tadlock summary, at A.R. 1097-98, Appendix I.
11
Id.at 114:18-23, A.R. at 1925.
8
tooth bud and most commonly occurs in the maxillary first molars. 12 “Ectopic
eruption of other teeth is rare, but can result in transposition.” 13 The following
photographs provide examples of ectopic eruption:
R-31A (showing upper and lower ectopically-erupted canines (images of non-
Antoine patients provided by Dr. Tadlock)), at A.R. 1031.14
See R-31L (showing an ectopically-erupted upper left central incisor (image of non-
Antoine patient provided by Dr. Tadlock)). 15 All of the scientific literature surveyed
by Dr. Tadlock describe ectopically erupted teeth as teeth that erupt “in the wrong
12
Id. at 143:17-18, 144:13-15, A.R. at 1954.
13
Id. at 145:8-10, A.R. at 1956.
14
See Vol. 1 at 149 for Dr. Tadlock’s description of this non-Antoine patient’s condition, at
A.R. 1960. Compare photos of Antoine patients, included infra at p. 18.
15
Id. at 150 for Dr. Tadlock’s description of this image, at A.R. 1961. Compare photos of
Antoine patients, included infra at p. 18.
9
place.”16 Teeth can ectopically erupt in sinus cavities, or through the side of the
face. 17 Based upon the well-known dental term, the vast majority of teeth that
Antoine represented to Medicaid as being ectopic eruptions were not ectopic
eruptions.
II. HHSC-OIG is responsible for protecting Medicaid from waste,
fraud and abuse. OIG is required by law to impose a payment
hold based on a credible allegation that a provider has
committed Medicaid fraud.
OIG is an independent oversight agency, administratively attached to HHSC.
OIG is responsible for investigating instances of waste, fraud and abuse in health
care services provided by HHSC, including Medicaid, and for enforcing state laws
relating to the provision of those services. Tex. Gov’t Code § 531.102; see also 1
Tex. Admin. Code § 371.1. Chapter 32 of the Human Resources Code authorizes
the OIG to recover damages and penalties from a person who presents or causes to
be presented to the department a claim that “contains a statement or representation
the person knows or should know to be false.” Tex. Hum. Res. Code § 32.032(b)(1).
The statutory authority for the rules governing OIG includes both chapters 32
and 36 of the Human Resources Code, and OIG may take administrative
enforcement measures against a person based upon a violation of either chapter. See
16
Id. at 153, at A.R. 1964.
17
Id. at 146:3-8, at A.R. 1957.
10
Tex. Gov’t Code § 531.001 et seq.; 1 Tex. Admin. Code § 371.1605 (2005); 1 Tex.
Admin. Code § 371.1617(5)(B) (2005) (which references and incorporates the Texas
Medicaid Fraud Prevention Act (“TMFPA”)). Therefore, the standard in the TMFPA
for determining whether a person acts with the requisite scienter to commit an
unlawful act is applicable in an enforcement action brought by the OIG, including a
payment hold proceeding. See Tex. Hum. Res. Code § 36.0011(a) (defining Culpable
Mental State).18
OIG is required by law to impose a payment hold “on receipt of reliable
evidence that the circumstances giving rise to the hold on payment involve fraud or
willful misrepresentation under the state Medicaid program in accordance with 42
C.F.R. Section 455.23.”19 Tex. Gov’t Code § 531.102(g)(2) (2011). “The State
Medicaid agency must suspend all Medicaid payments to a provider after the agency
determines there is a credible allegation of fraud for which an investigation is
pending under the Medicaid program against an individual or entity.” 42 C.F.R. §
18
For purposes of this chapter, a person acts “knowingly” with respect to information if
the person: (1)has knowledge of the information; (2) acts with conscious indifference to the
truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the
information. Proof of the person's specific intent to commit an unlawful act under Section
36.002 is not required in a civil or administrative proceeding to show that a person acted
“knowingly” with respect to information under this chapter. Id.
19
The mandatory payment-hold framework was introduced through provisions of the Affordable
Care Act, which amended the Social Security Act. Section 1862(o) broadly requires suspension
of payments pending an investigation of credible allegations of fraud. 42 U.S.C. § 1396b(i)(2)(c).
Section 1903(2)(c) provides for withholding of federal funds where the State fails to implement
section 1862(o). 42 U.S.C. § 1395y(o)
11
455.23(a)(1) (emphasis added).
Fraud is defined in the Government Code as “an intentional deception or
misrepresentation made by a person with the knowledge that the deception could
result in some unauthorized benefit to the person or to another person, and includes
any act that constitutes fraud under applicable federal or state law.” Tex. Gov’t
Code § 531.1011(1)20 (emphasis added). The definition incorporates unlawful acts
under the TMFPA.
A credible allegation of fraud “may be an allegation, which has been
verified by the State, from any source, including but not limited to the following:
. . . claims data mining [,] . . . patterns identified through provider audits [or] law
enforcement investigations.” 42 C.F.R. § 455.2. An allegation is credible if it has
“indicia of reliability and the State Medicaid agency has reviewed all allegations,
facts, and evidence carefully and acts judicially on a case-by-case basis.” Id.
Evidence is presumed to have indicia of reliability and may be adopted by
a court “without further inquiry if the defendant fails to demonstrate by competent
rebuttal evidence that the information is materially untrue, inaccurate or
unreliable.” United States v. Floyd, 343 F.3d 363, 372-73 (3rd Cir. 2003) (citing
United States v. Carbajal, 290 F.3d 277, 287 (5th Cir. 2002)).
20
In 2015, the legislative amended this statute to delete the italicized language. The amendment
did not take effect until September 2015; therefore, it is not applicable to this case.
12
OIG has additional authority to impose a payment hold if there is “reliable
evidence” a provider “committed fraud or willful misrepresentation regarding a
claim for reimbursement.” Tex. Hum. Res. Code § 32.0291(b) (2003).21 The
authority in Human Resources Code chapter 32 is duplicative of the authority in
Government Code chapter 531. However, § 32.0291(c) includes the standard for
maintaining the payment hold: “The department shall discontinue the hold unless
the department makes a prima facie showing at the hearing that the evidence relied
on by the department in imposing the hold is relevant, credible and material to the
issue of fraud or willful misrepresentation.” Tex. Hum. Res. Code § 32.0291(c)
(emphasis added).22
This means in a payment hold hearing, the OIG must present prima facie
evidence that is relevant, credible and material, that the provider acted with: (1)
knowledge of the truth or falsity of its representations; (2) conscious indifference
to the truth or falsity of its representations; or (3) reckless disregard of the truth or
falsity of its representations. Tex. Hum. Res. Code §§ 32.0291(c), 36.011.
(emphasis added).
21
Effective September 1, 2013 section 32.0291(b) of the Human Resources Code was amended.
A new subsection (c) was added to the statute. The changes are prospective and do not apply to
this case, which was heard in May 2013.
22
See In re E.I. DuPont de Nemours & Co., 136 S.W.3d 218, 223 (Tex. 2004) (“The prima facie
standard requires only the ‘minimum quantum of evidence necessary to support a rational inference
that the allegation of fact is true.’ Tex. Tech Univ. Health Scis. Ctr. v. Apodaca, 876 S.W.2d 402,
407 (Tex. App.—El Paso 1994, writ denied). ”).
13
III. Antoine billed Texas Medicaid for more than $8 million in
orthodontia services over a three-year period, and OIG placed
Antoine on payment hold.
Between November 1, 2008 and August 1, 2011, Medicaid paid Antoine
over $8,104,875.00, FoF 3, App. A at p. 3, at A.R. 1748. OIG initiated an
investigation of Antoine in 2011. Vol. 3, 195:1, A.R. at 2482. During the time
period of the investigation, Antoine treated approximately 6,550 Medicaid
patients. Vol. 3 at 200:12, A.R. at 2487. During its investigation, OIG collected a
statistically valid random sample 23 of 63 of Antoine’s Medicaid patient files. Vol.
3 at 200:20-208:7, A.R. at 2787.
The 63 patient files, which included diagnostic materials (x-rays, color
photographs, three-dimensional models, etc.) were independently reviewed by two
orthodontic experts: Dr. Charles Evans and Dr. Larry Tadlock. Based on the expert
review of the 63-patient sample, OIG instituted a 100% payment hold on Antoine’s
claims for reimbursement. 24 FoF 32, App. A at p. 13, at A.R.1756.
Both orthodontic experts relied upon their education and training in
23
OIG’s statistically valid sampling methodology was not at issue in the payment hold hearing.
The only evidence regarding the validity of OIG’s sampling and extrapolation procedure is
uncontroverted. See testimony of Deputy Inspector General for Enforcement, Vol 3, at 201-209,
A.R. at 2488-96.
24
Dr. Tadlock reviewed the sample after the payment hold was instituted, for purposes of testifying
at the payment hold hearing regarding the patient files.
14
reviewing the patient files to evaluate the patients’ conditions, and each expert
individually followed the TMPPM criteria for the corresponding years of service
(2008-2011). Both experts independently concluded Antoine inflated HLD scores
submitted to Medicaid. Vol. 3 at 289:23-290:3, 295:22-296:2, A.R. at 2576-77,
2582-83. OIG presented the following evidence, based on the experts’ review of
the 63 patients:
• Of the 63 patients, Antoine scored 61 (96.8%) as having severe handicapping
malocclusions, i.e., extreme deviations from the norm. See R-49, at A.R.
1097-98, App. I.
• Antoine certified that 61 patients had six or more ectopically-erupted teeth.
Ex. P-64.01 through P-64.63; R-49, at A.R. 1097-98, App. I.
• Antoine scored at least 50% of the allowable teeth as ectopic on each and
every HLD scoresheet Antoine submitted for authorization. See R-49, at A.R.
1097-98, App. I.
• No patient in the sample was eligible for Medicaid-covered comprehensive
orthodontics without Antoine’s scoring for ectopic eruption; further, Antoine
did not submit any narratives for any of the 61 patients, even if services could
be justified on other bases. Ex. P- 64.01 through P-64.63; Vol. 4 at 70:13-19,
A.R. at 2698.
• Dr. Kanaan scored 27 of the 63 patients’ HLDs. Of those 27 patients, he
scored 23 (85%) with the same eight teeth ectopic. Vol. 3 at 43-70, A.R. at
2330-57. Ex. P-64.01 through P- 64.63; R-49, at A.R. 1097-98, App. I.
• Antoine submitted prior authorization requests for comprehensive
orthodontics under the code D8080 for 61 of the 63 patients. Ex. P- 64.01
through P-64.63; Vol. 1, 176:14-20, 177:1-16, A.R. at 1987-88.
Dr. Larry Tadlock, D.D.S., 25testified:
25
Dr. Tadlock is a board-certified orthodontist. He is an Assistant Clinical Professor of
15
• Antoine’s HLD scoresheets were false and misrepresented the condition of
the patient’s teeth. Vol. 1 at 176:14- 20, 177:1-16, A.R. at 1987-88.
• 61 of 63 HLD scoresheets were incomprehensible because ectopic eruption is
a rare condition. Only 1.5-9% of the population has even one ectopic tooth.
Vol. 1 at 173:3-6, A.R. at 1984; see also R-51 at 8 (Thilander article describing
ectopic eruption as an “anomaly” that occurs in only 1.5-1.6% of a sample
population of 4724 patients), App. H.
• For ectopic eruption to occur more than once in the same patient is
“infinitesimally smaller.” Vol. 1 at 174:16-18, A.R. at 1985. See also R-31L,
supra, at p. 9.
• Because ectopic eruption is rare, occurring in between 1.5-9% of the
population, the chances of 61 patients in the 63-patient sample having 6 or
more ectopic anterior teeth is “not possible.” Vol. 1 at 173:3-6, 175:1, A.R. at
1984, 1986.
• The chance of 100% of patients in a sample having always at least six
instances of ectopic eruption, and always two or more bilateral instances, is
“zero. It’s not possible.” Vol. 1 at 175:1, 176:23, A.R. at 1986-87; R-49,
Tadlock summary, at A.R. 1097-98, App. I.
The following shows Antoine’s scoring of patients in the 63-patient sample:
Patient 1:
Pre-treatment intra-oral photos of Antoine Patient 1, P-01-0001:26
Orthodontics at Baylor College of Dentistry, responsible for supervising patient care, teaching
orthodontic residents, and performing research on orthodontics. He is one of only eight directors
of the American Board of Orthodontics (“ABO”) in the United States. As an ABO Director, Dr.
Tadlock is responsible for creating, writing, and administering board certification exam for
orthodontists. Specific to his experience with Medicaid, Dr. Tadlock has treated Medicaid patients
who were accepted and treated at Baylor. He estimates he has assessed “several hundred” HLD
scoresheets for potential Medicaid patients while at Baylor. Vol. 1 at 146-48, A.R. at 1957-59.
26
Dr. Tadlock concluded “[t]his patient’s occlusion is near perfect. . . . it might qualify as
passing the certification process from the American Board of Orthodonti[cs]. Vol. 1 at 158:18-
23. Compare photos of true ectopic eruptions, included supra at p. 9.
16
Antoine’s HLD scoresheet representing that Patient 1 has 8 ectopic teeth. P 01-
0013:
Patient 6:
Pre-treatment intra-oral photos of Antoine Patient 6. P-06-0003:27
06-0001
27
This patient does not have a single ectopic tooth according to Dr. Tadlock, and does not have a
severe handicapping malocclusion. Vol. 1 at 160:14-24, A.R.at 1971.
17
Patient 59:
Pre-treatment intra-oral photos of Antoine Patient 59, P-59-0018:
Antoine’s HLD scoresheet representing that Patient 59 has 10 ectopic
teeth. P-59-0017:
OIG based its decision to impose the payment hold on prima facie
evidence that Antoine fraudulently or willfully misrepresented HLD scores in
prior authorization requests, in violation of Tex. Gov’t Code § 531.102(a), and
1 Tex. Admin. Code §§ 371.1617(1)(A), (B), (I). 28
28
OIG also found that Antoine billed for services not reimbursable, in violation of 1 Tex. Admin.
Code § 371.1617(1)(K); and failed to maintain and provide required records, in violation of 1 Tex.
Admin. Code § 371.1617(2)(A). As a result, Antoine failed to comply with Medicaid program
requirements, and a payment hold was authorized under the Inspector General’s discretionary
authority. However, the Inspector General’s authority to impose discretionary payment holds was
challenged and then struck in Harlingen Family Dentistry v. Tex. Health & Human Servs. Comm’n,
452 S.W.3d 479 (Tex. App.—Austin 2014, pet. filed). Therefore, the State confines its arguments
to the mandatory payment hold under the credible allegation of fraud standard as codified in 42
C.F.R. § 455.23, Tex. Gov’t Code § 531.102(g)(2) (2011), and Tex. Hum. Res. Code § 32.0291(b).
18
IV. Antoine requested a hearing on the payment hold, and, after the
hearing and the ALJs’ recommendation that HHSC order OIG
to lift the hold, the EC reversed the PFD and ordered the hold to
remain in place.
Antoine requested a hearing to appeal the payment hold. SOAH ALJs
Howard Seitzman and Catherine Egan conducted a hearing in May 2013. The issue
was whether OIG presented prima facie evidence that was relevant, credible and
material that Antoine committed fraud or willful misrepresentations. Tex. Hum.
Res. Code § 32.0291(b).
The burden was not on the OIG to actually prove fraud or willful
misrepresentations; rather, the question was only whether OIG brought forward
prima facie evidence sufficient to maintain the payment hold. 29
After the hearing, ALJs Seitzman and Egan issued a PFD recommending
that HHSC order OIG to lift the payment hold. PFD, dated Nov. 4, 2013, A.R. at
1193-1238. OIG timely filed Exceptions to the PFD. Tex. Gov’t Code §
2001.062(b); 1 Tex. Admin. Code §§ 155.507(c)(1), 357.497. See Exceptions,
dated Nov. 22, 2013, A.R. at 1257-1344. Antoine filed a Response to OIG’s
Exceptions, and the ALJs issued a letter recommending an insignificant
modification to their PFD. See Letter, dated Jan. 16, 2014, A.R. at 1375-76.
29
The substantive allegations of Medicaid fraud against Antoine are pending in a separate lawsuit
brought by the State against Antoine and five other groups of provider defendants. State of Texas
v. Nazari, Cause No. D-1-GN-14-005380 (53rd Dist. Ct., Travis County, Texas).
19
HHSC issued a Final Order, adopting the OIG’s Exceptions and maintaining the
payment hold. See Order, dated Feb. 27, 2013, A.R. at 1387-1422. HHSC’s Final
Order was issued by HHSC ALJ Rick Gilpin, who the EC designated to review
the PFD and issue the final agency decision. See 1 Tex. Admin Code §
371.1617(a)(3); 1 Tex. Admin Code § 357.483(a)(1)-(2). Subsequently, OIG filed
a motion for rehearing. Mot., dated Apr. 2, 2014, A.R. at 1552-1650.30 After
reviewing the record, the EC issued the AFO. See Am. Final Order, dated, May 2,
2014, at App. A, and A.R. at 1744-85.
Antoine filed a motion for rehearing, which HHSC overruled. A.R. at 1787-
1810. Antoine then filed for judicial review in district court. After briefing and
argument, but without the submission of any evidence other than the
administrative record, the district court entered a judgment stating that the EC’s
AFO is reversed. The district court gave no explanation for the reversal. This
appeal followed.
30
Antoine also filed a motion for rehearing, erroneously with SOAH instead of with HHSC
Appeals Division. Mot., dated Mar. 17, 2014, A.R. at 1423-65; see also Tex. Gov’t Code §
2001.146 (motions for rehearing procedures); 1 Tex. Admin. Code § 357.488(b) (Filing and
Serving of Documents (“Documents are considered filed only when received by the HHSC
Appeals Division. . .”); 1 Tex. Admin. Code § 357.497(e) (“When the judge issues a proposal for
decision, the referring agency’s rules govern final orders and motions for rehearing.”). Because
Antoine filed the motion for rehearing in the wrong forum, the motion was a nullity, and the EC
was free to disregard it.
20
STANDARD OF REVIEW
The test for review of an agency action is not whether the agency reached the
correct conclusion, but whether some reasonable basis for the agency’s action exists
in the record. State v. Pub. Util. Comm’n, 883 S.W.2d 190, 203 (Tex. 1994) (citing
R.R. Comm’n v. Pend Oreille Oil & Gas Co., 817 S.W.2d 36, 41 (Tex. 1991)).
The district court reviewed HHSC’s AFO under the substantial evidence rule.
Tex. Gov’t Code § 2001.174. The Administrative Procedure Act (“APA”) provides
that the district court “may not substitute its judgment for the judgment of the state
agency on the weight of the evidence on questions committed to agency discretion
but . . . may affirm the agency decision in whole or in part” if the order is supported
by substantial evidence. Tex. Gov’t Code § 2001.174(1). The district court’s review
was limited to the administrative record. Tex. Gov’t Code § 2001.175(e). This Court
also reviews the AFO under the substantial evidence rule, without deference to the
judgment of the district court. Tex. Dep’t. of Pub. Safety v. Alfred, 209 S.W.3d 101,
103 (Tex. 2006) (per curiam). Employees Ret. Sys. of Texas v. Garcia, 454 S.W.3d
121, 132 (Tex. App.—Austin 2014 pet. denied).
The Court may affirm the AFO on any grounds that would support the
decision, and is not “bound by the reasons given by an agency in its order, provided
there is a valid basis for the action taken by the agency.” Tex. Health Facilities
Comm’n. v. Charter Med.-Dallas, Inc., 665 S.W.2d 446, 452 (Tex. 1984); see also
21
Tex. Emp’t Comm’n v. Hays, 360 S.W.2d 525, 527 (Tex. 1962). The Court may
uphold the AFO based on any legal basis shown in the record. Bd. of Trs. of the
Emps. Ret. Sys. v. Benge, 942 S.W.2d 742, 744 (Tex. App.—Austin 1997, writ
denied). If reasonable minds could have reached the conclusion that the EC
reached on the record presented, the AFO must be upheld. Bd. of Law Exam’rs v.
Stevens, 868 S.W.2d 773, 777-788 (Tex. 1994), cert. denied, Stevens v. Bd. of Law
Exam’rs, 512 U.S. 1206, 114 S. Ct. 2676 (1994); Tex. State Bd. of Med. Exam’rs
v. Birenbaum, 891 S.W.2d 333, 337 (Tex. App.— Austin 1995, writ denied).
In applying the substantial evidence standard to the AFO, the Court may not
substitute its judgment for that of the EC as to the weight of the evidence on
questions committed to his discretion. Stevens, 868 S.W.2d at 778; Gulf States
Utils. Co. v. Pub. Util. Comm’n, 841 S.W.2d 459, 474 (Tex. App.—Austin 1992,
writ denied). Although substantial evidence is more than a mere scintilla, the
evidence may actually preponderate against the agency decision and yet still
amount to substantial evidence supporting the result reached by the agency. State
v. Pub. Util. Comm’n, 883 S.W.2d at 204; City of El Paso v. Pub. Util. Comm’n,
883 S.W.2d 179, 185 (Tex. 1994); see also Tex. State Bd. of Dental Exam’rs v.
Sizemore, 759 S.W.2d 114, 116 (Tex. 1988).
The Court presumes that substantial evidence supports the AFO, and the
burden is on Antoine to overcome this presumption. Graff Chevrolet Co. v. Tex.
22
Motor Vehicle Bd., 60 S.W.3d 154, 159 (Tex. App.—Austin 2001, pet. denied);
Lewis v. Southmore Savings Ass’n, 480 S.W.2d 180, 183 (Tex. 1972); see also City
of El Paso v. Pub. Util. Comm’n, 883 S.W.2d at 184.
The AFO should be reversed or remanded only if the absence of substantial
evidence has prejudiced Antoine’s substantial rights. Locklear v. Tex. Dep’t of Ins.,
30 S.W.3d 595, 597 (Tex. App.—Austin 2000, no pet.). The Court may only reverse
or remand a matter “for further proceedings”: if substantial rights of Antoine have
been prejudiced because the administrative findings, inferences, conclusions, or
decisions are:
(A) in violation of a constitutional or statutory provision;
(B) in excess of the agency’s statutory authority;
(C) made through unlawful procedure;
(D) affected by other error of law;
(E) not reasonably supported by substantial evidence considering the reliable and
probative evidence in the record as a whole; or
(F) arbitrary or capricious or characterized by abuse of discretion or clearly
unwarranted exercise of discretion.
Tex. Gov’t Code § 2001.174(2).
In the district court, Antoine argued that the EC exceeded his authority when
he reversed several of the ALJs’ findings of fact and conclusions of law. Whether
the EC exceeded his authority is a question of law to be decided de novo. See, e.g.,
Tex. Ass’n of Psychological Assocs.v. Tex. State Bd. of Exam’rs of Psychologists,
439 S.W.3d 597, 602 (Tex. App.— Austin 2014, no pet.) (court reviews exercise
of authority de novo).
23
SUMMARY OF THE ARGUMENT
This case presents the issue of whether the EC acted within his authority when
he issued the AFO to maintain the payment hold on Antoine. Because the EC was
fully authorized to correct the ALJs’ misapplications of Medicaid law and policy he
did not exceed his authority when he rejected their PFD and issued the AFO. See
Tex. Gov’t Code § 2001.058(e)(1); Froemming v. Tex. State Bd. of Dental Exam’rs,
380 S.W.3d 787, 793 (Tex. App.—Austin 2012, no pet.); Sanchez v. Tex. State Bd.
of Med. Exam’rs, 229 S.W.3d 498, 516 (Tex. App.—Austin 2007, no pet.); see also
Akin v. Tex. State Bd. of Dental Exam’rs, No. 03-14-00390-CV, 2015 WL 1611803,
at *4-5 (Tex. App.—Austin Apr. 9, 2015, no pet. hist.). Further, the AFO is
supported by substantial evidence in all respects.
In reviewing the decision to issue the AFO, the Court must assume that the
AFO is valid; and to overcome the presumption of validity, Antoine has the burden
to establish that the AFO is not supported by substantial evidence or that the EC
exceeded his statutory authority in issuing the AFO. See Graff Chevrolet, 60
S.W.3d at 159 (plaintiff has burden of proving that agency’s order is not supported
by substantial evidence). In the district court, Antoine did not even argue that the
AFO is not supported by substantial evidence. Instead, Antoine confined its
argument and briefing to the issue of whether the EC exceeded his authority in
changing the ALJs’ findings of fact. Because Antoine did not brief or argue
24
substantial evidence in the district court that issue has been waived. See Akin, 2015
WL 1611803, at *3 n.1 Nonetheless, the State will show that the AFO is fully
supported by substantial evidence in the administrative record that: (a) the ALJs
misinterpreted and misapplied Texas law and Medicaid policy, and (b) the OIG’s
determination to impose the payment hold was based on prima facie evidence that
was relevant, credible and material to the question of fraud or willful
misrepresentation.
The State urges the Court to reverse the district court—i.e. reinstate the
AFO—on the basis that Antoine cannot carry its burden to establish that the AFO
was not supported by substantial evidence, nor can Antoine establish that the EC
exceeded his statutory authority.
ARGUMENT
I. The EC acted within his discretion to correct misapplications of
Medicaid law and policy by the SOAH ALJs.
The APA governs contested proceedings before HHSC. The APA expressly
defines the EC’s discretion to change ALJs’ proposed findings of fact and
conclusions of law after contested case hearings. The APA provides, in pertinent
part:
(e) A state agency may change a finding of fact or conclusion of
law made by the administrative law judge, or may vacate or
modify an order issued by the administrative law judge, only
if the agency determines:
25
(1) that the administrative law judge did not properly apply
or interpret applicable law, agency rules, written
policies provided under Subsection (c), or prior
administrative decisions;
(2) that a prior administrative decision on which the
administrative law judge relied is incorrect or should be
changed; or
(3) that a technical error in a finding of fact should be
changed.
Tex. Gov’t Code § 2001.058(e) (emphasis added). Thus, the EC was authorized to
change the ALJs’ incorrect legal and policy determinations. See Tex. Gov’t Code
§ 2001.058(e)(1); see also Froemming, 380 S.W.3d at 793; Akin, 2015 WL
1611803, at *4-5, *5 n.6; Smith v. Montemayor, 2003 WL 21401591, at *8 (Tex.
App.—Austin June 19, 2003, no pet.); Wood v. Tex. Comm’n Envtl. Quality, No.
13-13-00189-CV, 2015 WL 1089492, at *11 (Tex. App.— Corpus Christi, Mar.
5, 2015, no pet. hist.)
Consistent with the concept that agencies determine the meaning of their
policies and the laws they are committed to enforce, agencies have broad
discretion to modify “legislative facts” in PFDs. 31 See Tex. State Bd. of Med.
Exam’rs v. Dunn, 03-03-00180-CV, 2003 WL 22721659, at *3 (Tex. App.—
31
A “legislative fact” is a mixed question of fact and law and defining terms is an agency function.
F. Scott McCown & Monica Leo, When Can an Agency Change the Findings of Conclusions of an
ALJ?: Part Two, 51 Baylor L. Rev. 63, 69-70 (1999) (hereinafter “McCown & Leo”). A finding
of fact is a “legislative fact” where the finding affects not just one specific case, but is actually an
explication of agency policy and therefore may be applied to other cases or implicates agency
policy. Id.
26
Austin Nov. 20, 2003, no pet.) (“agencies are ‘relatively’ free to review and correct
an ALJ’s ‘legislative facts,’ which ‘provide a foundation for developing law, rules,
or policies and, consequently, affect the outcome of many cases.’”) (quoting
McCown & Leo, at 68-69); see also Sanchez, 229 S.W.3d at 515-16; Exxon Corp.
v. Railroad Comm'n, 993 S.W.2d 704, 710 (Tex. App.—Austin 1999, no pet.);
Montemayor, 2003 WL 2140151, *8.
The ALJs misconstrued Medicaid policy, ignored evidence, disregarded
competent testimony proffered by OIG, and created “expert” testimony not offered
by Antoine. The EC, acting with sound discretion, corrected the ALJs’ erroneous
interpretations, and their flawed findings and conclusions that flowed from their
initial errors. The EC fully explained each modification, as required by the APA,
demonstrating the substantial evidence necessary to support his modifications. See
Tex. Gov’t. Code § 2001.058(e).
A. The proper interpretation of Texas Medicaid policy is a
question of law to be determined by the EC. The EC properly
interpreted Medicaid policy in harmony with the governing
statutes and regulations, and Antoine has shown no basis for
the Court to deviate from the EC’s correct interpretation.
The proper interpretation and application of regulatory/statutory provisions
governing Medicaid and Medicaid policy are questions of law committed to the
discretion of the EC - not the ALJs. Thus, the EC was not bound to accept the
ALJs’ erroneous determinations regarding Medicaid policy concerning “ectopic
27
eruption.” See, e.g., R.R. Comm’n of Tex. v. Tex. Citizens for a Safe Future &
Clean Water, 336 S.W.3d 619, 629 (Tex. 2011) (“We must uphold the enforcing
agency’s construction if it is reasonable and in harmony with the statute.”); Sw.
Pharm. Solutions, Inc., v. Tex. Health & Human Servs. Comm’n, 408 S.W.3d 549,
557-58 (Tex. App.—Austin 2013, pet. denied); Froemming, 380 S.W.3d at 793;
Akin, 2015 WL 1611803, at *4-5.
The Akin court approved the board’s modifications of the ALJ’s proposed
finding and conclusion because the ALJ failed to properly interpret or apply the
statute to facts in evidence. Id. While the ALJ in Akin found Akin did not commit
a dishonest act, the board provided examples of evidence that showed the dentist
was dishonest or practicing dentistry illegally, and the district court upheld the
board’s order reversing the ALJ’s PFD. Id. Akin court also quoted with approval
Montemayor, 2003 WL 21401591, at *8. Akin, 2015 WL 1611803, at *5 n.6
In the instant case, in reversing the AFO (without explanation), the district
court implicitly determined the EC’s interpretation of Medicaid rules—especially
those related to ectopic eruption—was unreasonable and not in harmony with the
statutes he interpreted. The State presented substantial evidence at the district
court, discussed infra, through the admission of the administrative record,32 that
the EC’s interpretation of the Medicaid rules is reasonable and followed long-held
32
No additional evidence was presented at the district court.
28
principles of statutory construction. Antoine presented nothing to counter the EC’s
reasonable interpretation; therefore, the district court should not have disturbed the
EC’s decision.
B. The EC’s corrections of the ALJs’ errors in interpreting
Medicaid policy are entitled to respect from the Court.
The EC’s interpretation of the proper scope and limitations of Texas
Medicaid orthodontia policy is entitled to respect from the Court. See Texas
Citizens, 336 S.W.3d at 624; see also Atascosa Cnty. v. Atascosa Cnty. Appraisal
Dist., 990 S.W.2d 255, 258 (Tex. 1999); Gomez v. Tex. Educ. Agency, 354 S.W.3d
905, 913-17 (Tex. App.—Austin 2011, pet. denied); Sw. Pharm., 408 S.W.3d at
562; Tex. Gov’t Code § 311.023(6).
Where a statute is ambiguous, the Court must give serious consideration to
the interpretation of an agency charged with its enforcement. Texas Citizens, 336
S.W.3d at 625. In Texas Citizens, the Supreme Court held:
We have never expressly adopted the Chevron or
Skidmore doctrines for our consideration of a state
agency’s construction of a statute, but we agree with the
Commission that the analysis in which we engage is
similar. In our “serious consideration” inquiry, we will
generally uphold an agency’s interpretation of a statute it
is charged by the Legislature with enforcing, “‘so long as
the construction is reasonable and does not contradict the
plain language of the statute.’”
Id. (citations omitted). Deference to the agency’s interpretation is particularly
important where, as here, the policies, rules and statutes in question concern a
29
matter within the core expertise of the agency. See Zimmer US, Inc. v. Combs, 368
S.W.3d 579, 586 (Tex. App.—Austin 2012, no pet.)
Southwest Pharmacy is also instructive. The plaintiff pharmacy providers
challenged HHSC rules pertaining to Medicaid pharmacy reimbursements. The
outcome of the dispute turned, in part, on construction of the phrase “medical
assistance” as defined in Government Code chapter 531, Human Resources Code
chapter 32, and the rules adopted thereunder. Sw. Pharm., 408 S.W.3d at 560-61.
In siding with HHSC, the court noted that the disputed statutory language must not
be read in isolation, but rather, must be analyzed “in the context of the statutes as
a whole.” Id. “We must consider the role of the provisions in the full Medicaid
statutory scheme and in . . . context. . . And we must construe the provisions in a
way that is consistent with their underlying purpose and the policies they are
intended to promote.” Id. at 561. The court further noted:
Even if we were to conclude that there is vagueness,
ambiguity, or room for policy determinations in these
statute and rules, we would conclude that HHSC's
interpretation of the relevant code provisions and agency
rules is reasonable, in harmony with the statutes and rules,
and entitled to deference. We defer to the agency's
interpretation unless it is plainly erroneous or inconsistent
with the language of the statute or rule.. As the agency
designated to administer Medicaid, HHSC is charged
with overseeing a complex regulatory scheme, and
deference to its construction is particularly important.
An agency's construction does not have to be “the only--
or the best-- interpretation in order to warrant . . .
deference.” Considering the entire statutory scheme, the
30
goals and policies behind it, and the legislative history and
intent, we would conclude that HHSC's interpretation is
reasonable, does not conflict with the provisions'
language, and is entitled to deference.
Id. at 561-62 (emphasis added) (internal citations omitted). Here, the EC’s
interpretation of the meaning of ectopic eruption is reasonable, and is consistent
with Medicaid policy and applicable laws.
As explained in the AFO, the EC determined that “ectopic eruption” is a term
of art in the dental profession and should be interpreted for Medicaid just as it is
generally recognized in the field of dentistry, and consistent with the expert
opinions of Dr. Tadlock, Dr. Altenhoff and the Dr. Proffit textbook. The EC’s
interpretation of ectopic eruption is narrow, objective not subjective, and consistent
with Medicaid’s orthodontic policy of providing benefits to children with
dysfunctional severe handicapping malocclusions rather than providing benefits to
children who have solely cosmetic needs. If the EC did not correct the ALJ’s
erroneous interpretation of ectopic eruption, dental providers would be able to
apply a broad, subjective standard and use that subjective standard to qualify nearly
any patient regardless of need or Medicaid’s other limitations solely on the basis of
“ectopic eruption.” Such a scenario would fly in the face of Medicaid’s clear policy
of providing limited orthodontic benefits only for severe handicapping conditions
and not providing benefits for cosmetic reasons only.
The EC’s policy interpretation is also squarely within his core area of
31
expertise as the chief executive of the agency in charge of Texas Medicaid.
Therefore, it is entitled to deference from the Court. Texas Citizens, 336 S.W. at
629; Sw. Pharm., 408 S.W.3d at 561-62; Garcia, 454 S.W.3d at 137. This proper
interpretation by the EC is the lynchpin of the modifications to the ALJs’ PFD, as
discussed infra.
II. The EC did not exceed his authority in entering the AFO and
Antoine cannot establish otherwise.
Antoine cannot establish that the EC exceeded his authority in entering the
AFO. The standard of review for an abuse of discretion by a state agency is whether
the agency’s final decision: (1) ignores the factual record; (2) relies on facts not in
evidence; or (3) is not rationally connected to the factual record. City of El Paso, 883
S.W.2d at 184; State v. Pub. Util. Comm’n, 883 S.W.2d at 201; Heritage on the San
Gabriel v. Tex. Comm’n on Envt’l Quality, 393 S.W.3d 417, 423 (Tex. App.—Austin
2012, pet. denied), (quoting City of Waco v. Tex. Comm’n Envtl. Quality, 346
S.W.3d 781, 819-20 (Tex. App.—Austin 2011, pet. denied)).
The AFO is squarely based on the factual record from the SOAH hearing.
The AFO is 42 pages long and is replete with references to uncontested evidence.
App. A. Further, no reasonable argument can be made that the AFO relies on facts
not in evidence or that it is rationally unrelated to the evidence. In short, there is
no credible argument that the EC abused his discretion in rendering the AFO.
32
All of the EC’s modifications in the AFO were made to correct
misunderstandings and misapplications of Medicaid law and policy by the ALJs.
Substantial evidence exists to show the EC correctly maintained the payment hold,
and Antoine cannot present evidence to the contrary; therefore, the Court should
uphold the AFO.
A. The ALJs misunderstood and misapplied Texas Medicaid law
and policy and the EC corrected the misunderstanding with a
proper construction of law and policy.
The ALJs incorrectly concluded that OIG failed to present prima facie
evidence that is “credible, reliable, or verifiable, or that has indicia of reliability”
that Antoine engaged in fraud or willful misrepresentation in filing its requests for
prior authorization and claims for payment with Texas Medicaid. Consequently
the ALJs recommended that the EC order the OIG to lift the payment hold in its
entirety. See PFD proposed FoF Nos. 48-50, at pp. 40-41, A.R. at 1234- 35.
The ALJs’ incorrect findings, conclusions, and ultimate recommendation
rested on their erroneous determination that Texas Medicaid adopted a “special”
definition of the term “ectopic eruption” that is subjective and broader than the
meaning of the phrase in the general practice of dentistry. This is clearly at odds
with the EC’s interpretation that ectopic eruption means the same thing in Texas
Medicaid as it does in the general practice of dentistry. In making this
determination, the ALJs ignored the plain language of the policy and the testimony
33
of the only witnesses qualified to testify what Texas Medicaid policy means. The
ALJs’ mistaken construction of ectopic eruption effectively destroys the
limitations of Texas law and Medicaid policy which restrict orthodontia to
children who suffer from a “severe handicapping malocclusion.” 25 Tex. Admin.
Code § 33.71.
Rather than concluding that the definition of ectopic eruption is subjective,
the ALJs should have adopted the agency’s own construction, as presented by
agency staff witnesses and by the State’s testifying expert.33 The record presented
by the State shows that the TMPPM’s instruction regarding ectopic eruption is not
vague and is consistent with the widely recognized understanding of ectopic
eruption. See Vol.1, 236:3-15, A.R. at 2047 (Dr. Tadlock testifying that the
definition of ectopic eruption is learned at every dental school and in every
orthodontic program in the country); 34 see also Vol. 2 at 84:23-24, A.R. at 2135
33
Dr. Tadlock is the only board-certified orthodontist who testified in this case. He is one of only
eight directors nationally on the American Board of Orthodontists and is the incoming Chair of the
ABO clinical committee, which administers the clinical exam to orthodontic residents nationally.
Vol. 1, at 133:10-134:20, A.R. at 1944-45.
34
Dr. Tadlock reviewed nearly 1,300 articles discussing “ectopic eruption.” Vol. 1, at 152:1-
154:11, A.R. at 1963-65. As Dr. Tadlock noted, “The bottom line is this, there are no references to
teeth that are rotated or tipped. There are -- ectopic eruption in every article is a tooth that is away
from, it is out of place, it is in the wrong place. Not most of them, many of -- not most of them, all
of them.” Id. at 153:1-6 (emphasis added), A.R. at 1864; see also 154:4-11, A.R. at 1965 (“But in
every case, they are teeth that are out of the position, they are not here in turn; they are out, they
are somewhere else. That's the definition of ectopic eruption that existed that started in 1938 or
somewhere before then. It has existed in its same form since then, up to '87 when Dr. Proffit wrote
its eruption in the wrong place, and that definition has not changed.”) (emphasis added).
34
(where Antoine’s expert Dr. Orr acknowledged that “ectopic” means “out of
place,” and that this meaning is found “in medicine all over.”).
The administrative record reflects HHSC’s long-standing requirement that
medical and dental terms be interpreted for Medicaid purposes just as those terms
are construed for non-Medicaid patients. Ex. R-14, (2008 TMPPM) at § 1.2.5, at
App. G; Ex. R-15 (2009 TMPPM), at § 1.4.5, at App. F; Vol. 1, 93:2-9, 94:16-
23, 111:11-14, A.R. at 1904-05; Vol. 3, 193:5-194:1, 241:5-11, 249:11-250:19,
A.R. at 2480-81, 2528, 2536-37.
Dr. Tadlock’s testimony that ectopic eruption is generally understood
within the dental/orthodontic profession as a “tooth that is out of place,” is not
only supported by the medical literature and the testimony of the State’s Medicaid
policy witness, Dr. Altenhoff, it is also the only competent expert testimony of
record. See generally Dr. Tadlock’s testimony at Vol. 1, at 152:1-154:11, A.R. at
1963-65; see also Vol. 3, 240:22-241:4, A.R. at 2527-28 (testimony that Dr.
Altenhoff is the person most knowledgeable about Medicaid policy), and Vol. 3,
174:19-175:7 (Antoine’s dentist Dr. Kanaan acknowledging that Dr. Altenhoff is
the expert on what Medicaid covers and does not cover), A.R. at 2461-62.35
The ALJs’ error in disregarding the testimony of Drs. Tadlock and
35
When asked by the ALJ if conditions would qualify as ectopic eruption after the January 2012
clarifying amendment, Dr. Kanaan answered: “You would need to ask Dr. Altenhoff.” Vol. 3,
174:19-175:4, A.R. at 2461-62.
35
Altenhoff was magnified because they misconstrued what Antoine’s orthodontist,
Dr. Kanaan actually said. The ALJs incorrectly asserted that Dr. Kanaan
concluded that Patients 36, 37, 42, 43, and 47 each presented a “severe
handicapping malocclusion.” See PFD at 26-27, A.R. at 1220-21. This statement
is not supported by the evidentiary record. Of these patients, the only ones for
which Dr. Kanaan made such statement were Patients 36 and 47. Vol. 3, at 149:3-
4, A.R. at 2436 (describing Patient 36 as a “100 percent dysfunctional
handicapping case”); Vol. 3, at 161:23-162:6, A.R. at 2448-49 (opining that
Patient 47 presented “dental necessity, medical necessity, hundred -- hundred
percent handicap malocclusion”). For the other patients, Dr. Kanaan merely stated
that the patient, in his opinion, needed orthodontic treatment. Vol. 3, at 156:16-19
(Patient 37) (answering “100 percent, 120 percent” when asked patient had a “true
orthodontic need”), A.R. at 2443; Vol. 3, at 155:1-6 (Patient 42) (answering
“correct, hundred percent” when asked if case was an example of “true orthodontic
need”), A.R. at 2442; Vol. 3, at 159:12-16 (Patient 43) (agreeing that the patient
had a “true orthodontic need for braces”), A.R. at 2446. This distinction is more
than a semantic one, as the standard for Medicaid coverage is “severe
handicapping malocclusion” and not merely “true orthodontic need.” See 25 Tex.
Admin. Code § 33.71.
Taken together, testimony and evidence presented at the administrative
36
hearing, coupled with deference that should be given to the EC’s interpretation of
Texas Medicaid policy, 36 illustrate that: (a) the ALJ’s incorrectly interpreted and
applied Medicaid policy; (b) the EC was authorized to correct misapplications of
law and policy; and (c) the EC did not exceeded his authority in correcting the ALJs.
As a result, the Court should affirm the AFO.
1. The rules of statutory construction govern questions of
agency policy and administrative rules.
In determining the proper scope and limitations of Medicaid policy, and the
administrative rules of HHSC implementing Medicaid policy, the Court is guided
by the rules governing statutory construction. See Boswell v. Brazos Electric
Power, 910 S.W.2d 593, 599-600 (Tex. App.—Fort Worth 1995, writ denied);
Tex. Gov’t Code § 311.002(4).
In construing a statute, the primary objective is to ascertain and give effect
to the intent of the legislature. Cont’l Cas. Ins. Co. v. Functional Restoration
Assocs., 19 S.W.3d 393, 402 (Tex. 2000) (citing Liberty Mut. Ins. Co. v. Garrison
Contractors, Inc., 966 S.W.2d 482, 484 (Tex.1998)); Texas Citizens, 336 S.W.3d
at 624; Tex. Gov’t Code § 312.005. In so doing, courts look first to the plain and
common meaning of the statute's words. See Tex. Gov’t Code § 311.005;
Fitzgerald v. Advanced Spine Fixation Sys., Inc., 996 S.W.2d 864, 865 (Tex.1999).
36
Discussed infra.
37
Courts will consider the entire statute, not simply the disputed portions. State v.
Terrell, 588 S.W.2d 784, 786 (Tex.1979). Each provision must be construed in the
context of the entire statute of which it is a part. Bridgestone/Firestone, Inc. v.
Glyn-Jones, 878 S.W.2d 132, 133 (Tex.1994)
The Code Construction Act, Government Code chapter 311, provides
additional guidelines for statutory interpretation. For instance, words and phrases
should be read in context, not in isolation. Tex. Gov’t Code § 311.011(a). Words
and phrases that have acquired a technical or particular meaning shall be construed
accordingly. Tex. Gov’t Code § 311.011(b). The entire statute is intended to be
effective. Tex. Gov’t Code § 311.021(2). A just and reasonable result is intended;
one that is feasible of execution. Tex. Gov’t Code §§ 311.021(3), (4). The public
interest is favored over any private interest. Tex. Gov’t Code § 311.021(5).
In construing a statute a court may consider: (1) the object sought to be
obtained; (2) the consequences of a particular construction; and (3) an agency’s
construction of a statute that is committed to the agency for enforcement. Tex.
Gov’t Code §§ 311.023(1), (5), (6).
2. The ALJs ignored statutes, rules, and evidence and made
fundamental errors in interpreting and applying Texas
Medicaid policy. The misapplications were properly
corrected by the EC.
The EC acted within his authority and sound discretion when he applied
principles of statutory construction and declined to adopt the ALJs’
38
misconstruction of Texas Medicaid policy. The EC corrected fundamental errors
in the ALJs’ interpretation of Texas Medicaid Policy.
First, the ALJs erroneously determined that the TMPPM includes a special
definition of ectopic eruption that is capable of different interpretations in different
circumstances. Under this interpretation, the ALJs found that Antoine’s scoring of
twisted and rotated teeth as ectopic was acceptable. However twisted and rotated
teeth are normal and do not impair function. See, e.g., note 34, supra. Therefore,
the ALJs’ misinterpretation runs afoul of the plain language of Texas Medicaid
policy, as set forth in the TMPPM and in HHSC rules, which clearly states the
Medicaid orthodontia benefit is limited to cases where the patient presents a
“severe handicapping malocclusion.” 25 Tex. Admin. Code § 33.71; Ex. R-15 at
§ 19.19, at App. F. Furthermore, the ALJs’ erroneous interpretation violates a
fundamental requirement that law and agency policy should be construed
consistently with their plain language. Texas Citizens, 336 S.W.3d at 624. It was
therefore proper for the EC to correct these misinterpretations.
Second, the specific instruction regarding “ectopic eruption” should have
been construed by the ALJs in the overall context of Medicaid’s limited
orthodontia benefit policy. Tex. Gov’t Code § 311.011(a). Instead, the ALJs
examined the ectopic eruption discussion in the TMPPM in isolation, and without
regard to the remainder of the TMPPM or overall objectives of Texas Medicaid
39
policy. In fact, the ALJs applied an interpretation of the meaning of ectopic
eruption that was not only contrary to plain language of Medicaid law and policy,
it was also fundamentally at odds with the overall objective of the policy. The
ALJs’ liberal interpretation of the meaning of ectopic eruption 37 was erroneous
because it violated the TMPPM’s clear direction that providers should be
conservative in scoring the HLD. See, e.g., Ex. R-15 at § 19.21, at App. F.
(“Providers should be conservative in scoring. Liberal scoring will not be helpful
in the evaluation and approval of the case.”). 38 Moreover, the ALJs’ construction
of “ectopic eruption” in isolation from the overall context of Medicaid’s policy
also violated the requirement to consider the disputed portions of the policy within
the policy as a whole. Bridgestone/Firestone, Inc. v. Glyn-Jones, 878 S.W.2d 132,
133 (Tex. 1994).
The ALJs’ construction of Medicaid policy violated several additional
37
The absurdity of the ALJs’ construction is illustrated by Antoine’s expert, Dr. Orr, who
testified that in his broad reading of the Manual’s instruction “. . . to me, semantically it has a
limitless interpretation as far as the recognition by competent dentists of teeth out of position.”
Vol. 2, 148:23-149:2, A.R. at 2199-2200. The ALJs’ interpretation of the instruction renders the
word “unusual” in the instruction meaningless, a result that violates canons of statutory
construction. See, e.g., TGS-NOPEC Geophysical Co. v. Combs, 340 S.W.3d 432, 439 (Tex.
2011). As Dr. Tadlock testified, based on medical literature, nearly 80 percent of the population
has teeth that are crooked to some degree, and therefore there is nothing “unusual” for teeth to
erupt in a manner that is not straight or ideal. Vol. 1, at 157, A.R. at 1968.
38
The idea that HHSC would eviscerate Medicaid orthodontic policy and benefit limitations by
promulgating a new and more liberal definition of a widely understood term –– is, at best
counterintuitive.
40
tenets of statutory construction in the Code Construction Act:
• The ALJs ignored the meaning of ectopic eruption generally understood in the
dental profession, in violation of Tex. Gov’t Code § 311.011(b) (terms that
have acquired technical or particular meanings shall be construed accordingly);
• The ALJs’ broad interpretation of ectopic eruption rendered the limiting
language in State regulations (e.g., 25 Tex. Admin. Code § 33.71) and in
Medicaid policy (e.g., Ex. R-15, at § 19.19, at App. F) ineffective, in violation
of Tex. Gov’t Code § 311.021(2) (the entire statute is presumed to be effective);
• The ALJs’ interpretation leads to an “ectopic eruption in the eye of the
beholder” standard, which is absurd given scarce Medicaid resources and
HHSC statements regarding the limited nature of the orthodontic benefit.
Opening the definition to the subjective interpretation of providers (“if the
provider says its ectopic eruption, then it’s ectopic eruption”) also deprives
Medicaid policy makers of their statutory and regulatory responsibility for
defining the scope of the benefit. Thus the ALJs’ interpretation violates Tex.
Gov’t Code § 311.021(3) (a just and reasonable result is intended), and Tex.
Gov’t Code § 311.021(4) (a result feasible of execution is intended);
• The ALJs’ construction favors only the private pecuniary interests of
unscrupulous providers, at the expense of taxpayers and truly eligible Medicaid
recipients. Thus, the ALJs’ interpretation violates Tex. Gov’t Code §
311.021(5) (public interest is favored over any private interest);
• The ALJs failed to consider the purposes of Medicaid policy: their construction
does not advance the goal of preserving scarce Medicaid dollars by limiting
orthodontic reimbursements to cases of severe handicapping malocclusion.
Thus, the ALJs’ interpretation violates Tex. Gov’t Code § 311.023(1) (a court
considers the object sought to be obtained by the statute); and
• The ALJs failed to consider the consequences of their interpretation. Under
their interpretation, any provider’s prior authorization request for
comprehensive orthodontia will be approved, so long as the provider scores the
HLD with a 26 or greater – without regard to the true condition of the patient.
This has far reaching implications for the Medicaid program, particularly in
light of the ALJs’ acknowledgement (proposed FoF No. 25) that HHSC’s
Medicaid claims processing contractor, TMHP, abrogated its responsibility to
review clinical data submitted with prior authorization requests. The ALJs’
interpretation violates Tex. Gov’t Code § 311.023(5) (a court considers the
consequence of a particular construction).
41
It was therefore proper for the EC to correct these misinterpretations.
Finally, the ALJs’ interpretation of the Medicaid meaning of ectopic
eruption was contrary to HHSC’s long-held and consistent construction of the
phrase. OIG presented evidence during the hearing that a January 2012
amendment to the TMPPM language addressing ectopic eruption was intended to
clarify the Medicaid program’s long-standing interpretation, not to implement a
substantive change in policy. See testimony of Dr. Linda Altenhoff, Vol, 1 at 93:2-
9, 94:16-23, A.R. at 1904-05; and testimony of Deputy Inspector General for
Enforcement, Vol. 3 at 193:5-194:1, 294:21-23, A.R. at 2480-81, 2581. This
testimony from Medicaid program officials was uncontroverted.
Nevertheless, the ALJs erroneously concluded that the January 2012
language was intended to effect a substantive change to the “definition” of ectopic
eruption. In the district court, Antoine characterized the ALJs’ determinations
regarding the effect of the January 2012 language change as a finding of
adjudicative fact that the EC was not allowed to alter. Antoine is wrong. Whether
the language change in the TMPPM was intended to be substantive or clarifying
is a question of law, committed to the discretion of the EC. Sw. Pharm. Solutions,
408 S.W.3d at 561-62; Boswell, 910 S.W.2d at 599-600. It was therefore proper
for the EC to correct these misinterpretations.
42
B. Substantial evidence exists to show that Antoine committed
fraud or made willful misrepresentations necessary to
maintain the payment hold. The EC properly corrected the
ALJs’ errors, and Antoine cannot establish that the EC
exceeded his authority.
The ALJs erroneously determined that there exists a special definition for
ectopic eruption under the Medicaid Program—a definition that, as described
supra, is inconsistent with Medicaid’s limited orthodontic benefit. As a result, they
found that none of the HLD scoresheets Antoine submitted included false
statements or misrepresentations. Consequently, they wrongly concluded that
Antoine’s conduct was neither fraudulent nor willfully misrepresentative.
In reaching this conclusion, the ALJs ignored substantial evidence of
Antoine’s conduct, disregarded the testimony of the OIG’s expert, and
impermissibly created “expert” opinions from the testimony of Antoine’s Drs.
Nazari and Kanaan.
Antoine did not address the issue of substantial evidence in its district court
brief. Accordingly, Antoine waived any argument that the AFO is not supported
by substantial evidence. See Akin, 2015 WL 1611803, at *3 n.1. This alone should
be enough to affirm the AFO. Nevertheless, the State will show that the AFO is
fully supported by substantial evidence, and in so showing will establish that the
district court erred in reversing the AFO.
43
1. Providers have a duty to know and follow law and
policy.
In reaching their flawed interpretation of Medicaid policy, the ALJs ignored
Antoine’s duty, as a matter of law, to understand and comply with Medicaid
requirements, standards, and procedures. See Heckler v. Community Health Servs.,
467 U.S. 51, 63-65 (1984). Heckler involved the Government’s recovery of
payments incorrectly made to a Medicare provider, who contended the
Government was estopped from recovering because the provider relied on
authorization by a fiscal intermediary. Id. at 53, 60. The Heckler Court rejected
the availability of estoppel. Heckler found that the provider had lost no legal right
because it was never entitled to the money in the first place. Id. at 61-62.39 Heckler
also found that the provider had a duty to know the provisions under which it
received government funds. Id. at 64. The Court noted:
Justice Holmes wrote: “Men must turn square corners when they deal
with the Government” (citing Rock Island, A. & L.R. Co. v. United
States, 254 U.S. 141, 143 (1920)). This observation has its greatest
force when a private party seeks to spend the Government’s money.
Protections of the public fisc requires that those who seek public
funds act with scrupulous regard for the requirements of law;
respondent could expect no less than to be held to the most
demanding standards in its quest for public funds. This is consistent
with the general rule that those who deal with the Government are
expected to know the law and may not rely on the conduct of
Government agents contrary to law.
39
See also Personal Care Products, Inc. v. Hawkins, 635 F.3d 155 (5th Cir. 2001) (noting that
providers have no property interest in Medicaid reimbursement receivables).
44
Id. at 63; see also N. Mem’l Med. Ctr. v. Gomez, 59 F.3d 735, 739 (8th Cir. 1995)
(participants in the Medicaid program have a “duty to familiarize themselves with
the legal requirements” of Medicaid procedures). Providers may not claim after
getting caught in a lie that they interpreted a term in a manner that contradicts
Medicaid policy, federal and state law, and the industry-wide understanding of the
term. Likewise, Antoine’s misrepresentations were not excused and should not
have been given credit by the ALJs. The EC was well within his authority to
correct the ALJs misapplication and misinterpretations of Medicaid policy.
Therefore, the Court should affirm the AFO.
2. Dr. Kanaan’s scoring pattern shows, at a minimum,
he acted with conscious disregard or reckless
indifference to the truth or falsity of his
representations of patient conditions.
Dr. Kanaan’s scoring pattern shows substantial and reliable evidence of
fraud: he scored 27 of the 63 patients in the sample, and of those 27 patients, Dr.
Kanaan scored 23 (85%) as having the same eight teeth ectopic. Vol. 3 at 43-70,
A.R. at 2330-57. Ex. P-64.01 through P-64.63; R-49, Tadlock summary, at A.R.
1097-98, App. I. The rate of occurrence of ectopic eruption in the cases scored by
Dr. Kanaan flies in the face of expert testimony from disinterested
orthodontists that, according to the scientific literature, ectopic eruption is rare
and the incidence of even one tooth ectopic occurs only in between 1.5 and 9
45
percent of the population. 40 The chances that 85% of Dr. Kanaan’s patients would
each have the same eight ectopic teeth, when less than 10% percent of the
population has even one ectopic tooth, is infinitesimal. See Dr. Tadlock’s
testimony, Vol. 1 at 174-175, A.R. at 1985-86. Although the ALJs made passing
note of Dr. Kanaan’s scoring pattern, they failed to draw any inferences from this
conduct, nor did they explain how this evidence relates to the OIG’s burden to
continue the payment hold.41See 42 C.F.R. § 455.2 (a Medicaid agency may
receive credible allegations of fraud from any source, including “patterns
identified through provider audits.”).42
Additionally, OIG presented reliable evidence that Antoine submitted
fraudulently scored HLD scoresheets for 61 of the 63 patients by falsely
40
Dr. Kanaan testified the ectopic eruption is so rare that he has never treated a private-pay patient
for a single ectopically-erupted tooth. Vol. 3 at 96:6-9, A.R. at 2383. Yet, he also testified that he
does not diagnose Medicaid and private-pay patients differently. Id. at 17:22-25, A.R. at 2304. Dr.
Kanaan even testified that the very same mouth that has ectopically-erupted teeth for Medicaid
purposes is a prime example – the very example he uses on his other practice’s website– of
crowding. Vol. 3 at 20:25-21:1, A.R. at 2307-08 (the photo on his website is an example of
crowding), 21:5-20, A.R. at 2308 (explaining that the photo is of ADC’s Medicaid patient), 25:5-
25:8, A.R. at 2312 (stating that he scored this patient as ectopic).
41
None of the patients in the sample were eligible for Medicaid-covered comprehensive
orthodontics without Antoine’s score for ectopic eruption: excluding those ectopic eruption
scores, Antoine’s sample HLD scores ranged from 0 to 19. See R-49, Tadlock summary, at A.R.
1097-98, App. I. Assuming arguendo that each of these patients had two instances of the rare
condition of anterior ectopic eruption, they still would not have been eligible for Medicaid-
covered comprehensive orthodontics, as they could not achieve the qualifying score of 26.
42
The evidentiary burden on OIG in this proceeding is very low. The evidence must have
“indicia of reliability.” In other words, it is reliable unless rebutted and shown to be immaterial,
untrue, inaccurate or unreliable
46
representing that each of these 61 patients had six or more ectopically-erupted teeth.
See R-49, Tadlock summary, at A.R. 1097-98, App. I. In light of the commonly
understood meaning of ectopic eruption as established by the testimony of Dr.
Tadlock and Dr. Altenhoff, the egregiousness of Antoine’s scoring pattern shows
reliable prima facie evidence of fraud or willful misrepresentations and satisfied
the OIG’s burden to maintain the payment hold. Tex. Gov’t Code § 531.102(g)(2).
3. The ALJs compounded their errors by relying on
“experts” who misunderstood and misapplied Texas
Medicaid policy.
The ALJs expressly declined to rely on Antoine’s proffered experts, Orr and
Ornish, for their determinations regarding ectopic eruption. PFD at 28, A.R. at
1222. Instead the ALJs attempted to refute Dr. Tadlock’s expert testimony by
citing to the testimony of Drs. Nazari and Kanaan. However, Antoine did not
proffer or qualify either Dr. Nazari or Dr. Kanaan as an expert, and the ALJs erred
in considering them experts.43 See also Petitioner’s Expert Designations (listing
43
The State objected to Dr. Kanaan being treated as an expert witness. Vol. 3 at 128:2-5, A.R. at
2415. The ALJs abused their discretion when they considered Dr. Kanaan’s testimony as an expert.
Vol. 3 at 128:6-16 (ALJ: “Well he [Dr. Kanaan] may not have been offered as an expert but he
certainly is qualified as an expert as much as any other.”). The ALJs, sua sponte designated Dr.
Kanaan as an expert. Vol. 3 at 129: 3-5, 19-22, A.R. at 2416 (allowing a treatise to be shown to
Dr. Kanaan to show “what the expert relied on” and “showing in part what Dr. Kanaan relied upon
in forming his expert opinions”). Nor did Antoine ever offer or qualify Dr. Kanaan as an expert
witness. Because of the ALJs’ abuse of discretion in designating a party opponent as an expert, the
EC acted well within his discretion in correcting any proposed findings or conclusions that were
predicated on the ALJs’ erroneous ruling.
As for Dr. Nazari, Antoine never offered him as an expert. Vol. 4, A.R. 2633-2794. The ALJs in
their PFD, again sua sponte, designated Dr. Nazari as an expert. See PFD at 28 (discussing Dr.
47
Dr. Orr and Dr. Ornish), A.R. at 356-74. The ALJs also failed to note Dr. Nazari’s
testimony that he learned to score the HLD index “for Medicaid” from Dr. Orr.
Vol. 4 at 137:17-25, A.R. at 2765.44 Thus, even though the ALJs putatively did not
rely on Orr and Ornish, their reliance on Dr. Nazari is misplaced because his
opinions are derivative of Dr. Orr, who incorrectly opined that Texas Medicaid
adopted a special liberal definition of ectopic eruption.45 The ALJs therefore erred
by relying on providers, for their interpretation of Medicaid policy; and by
disregarding the testimony of Medicaid policy witnesses and qualified experts. See
Sw. Pharm., 408 S.W.3d at 561-62; Wood v. Tex. Comm’n Envtl. Quality, 2015
WL 1089492, at *6.
Nazari’s testimony as an expert), A.R. at 1222. The EC correctly modified any findings or
conclusions relying on the ALJs’ erroneous designation of Dr. Nazari as an “expert.”
44
Dr. Nazari testified the methodology he applied for ectopic eruption was to include any teeth
that were "rotated, the slanted leaning teeth" based on what he learned from Dr. Orr a decade
prior. Vol. 4, at 102:22-103:4, 138:18-23, A.R. at 2730-31, 2766 (including "twisted or turned or
crooked" teeth). This description, comports with neither the generally-accepted scientific
understanding of the term "ectopic eruption" nor the instruction of the TMPPM which refers to
"an unusual pattern of eruption."
45
The ALJs summarily, and incorrectly, stated that the HLD scores of Dr. Orr and Dr. Ornish, ,
were “generally similar” to Antoine’s scores and that their testimony was “cumulative” of the
testimony of Drs. Nazari and Kanaan; the ALJs asserted that they did not rely upon the testimony
of either Dr. Orr or Dr. Ornish. PFD at 28, A.R. at 1222. OIG objected to this supposed cursory
treatment of Antoine’s experts for two reasons. First, the evidence shows Dr. Nazari’s
understanding of HLD scoresheets was directly based on training he received from Dr. Orr. Vol.
4, at 137-38, A.R. at 2765-66; See also Respondent’s Closing Brief at 13, 33-37, A.R. at 1001,
1021-22. Second, it is factually incorrect to conclude that Dr. Ornish’s scores were “generally
similar” to Antoine’s– in fact, Dr. Ornish, the only expert orthodontist retained by Antoine, scored
13 of the 63 Antoine patients as having an HLD score less than 26. Thus, Antoine’s own expert
opined that nearly 21 percent of the Antoine patients did not qualify for Medicaid based on the
HLD score.
48
III. Every modification made in the EC’s AFO is supported by
substantial evidence and Antoine cannot establish otherwise.
For each modification that he made to the ALJs’ PFD, the EC met the
requirements to support his changes to the PFD in his AFO. See e.g., Flores v.
Emps. Ret. Sys. of Tex., 74 S.W.3d 532, 540 (Tex. App.—Austin 2002, pet.
denied); Pierce v. Tex. Racing Comm’n, 212 S.W.3d 745, 755 (Tex. App.—Austin
2006, pet. denied); see also Dunn, 2003 WL 22721659, at *1. There must be a
rational connection between an underlying agency policy and the altered finding
of fact or conclusion of law. See, e.g., Heritage on the San Gabriel, 393 S.W.3d at
440-4; State v. Mid-South Pavers, Inc., 246 S.W.3d 711, 728 (Tex. App.–Austin
2007, pet. denied); Levy v. Tex. State Bd. of Medical Exam’rs, 966 S.W.2d 813,
816 (Tex. App.–Austin 1998, no pet.).
In the district court, Antoine specifically claimed that the EC erred in
changing Findings of Fact 45-50 and Conclusion of Law 13. Because Antoine
limited its arguments to those findings of fact and conclusion of law, it has waived
argument as to any other changes the EC made to the AFO. Each of the EC’s
modifications to the contested findings and conclusions was authorized by law and
fully supported by substantial evidence in the record.
A. Finding of Fact No. 45
Finding of Fact No. 45 reads:
In reviewing the 63 ADC patient files in the statistically valid
49
random sample, Dr. Tadlock applied the definition of ectopic
eruption that is generally recognized within the dental profession
and scored the patients as instructed by the Manuals. Dr.
Tadlock properly applied Medicaid policy.
As proposed by the ALJs, proposed FoF No. 45 read: “Dr. Tadlock did not
apply the Manual’s definition of ectopic eruption in scoring the HLD index for the
63 patients.” A.R. at 1234.
The EC was authorized to modify proposed FoF No. 45 because it addresses
a mixed question of fact and law, and is therefore a “legislative finding.” 46 See
Sanchez, 229 S.W.3d at 515-16; Dunn, 2003 WL 22721659, at *3 (quoting
McCown & Leo, at 68-69); Montemayor, 2003 WL 2140151, *8.
The ALJs’ proposed FoF No. 45 was a legislative finding because it was
expressly premised on the erroneous and impermissible interpretation that Texas
Medicaid policy incorporates a special definition for ectopic eruption. The ALJs’
proposed FoF No. 45 had two incorrect assumptions: (1) Medicaid had a special
definition for ectopic eruption; and (2) Dr. Tadlock failed to apply Medicaid
policy. Neither assumption is accurate.
The EC fully explained the reasons for his modification of FoF No. 45 in
his AFO. See App. A, at pp. 21-23, A.R. at 1764-66. This explanation provides
the substantial evidence needed to support the AFO. Antoine cannot establish a
46
See McCown & Leo, supra note 31.
50
lack of substantial evidence on the part of the EC, and consequently, the Court
should affirm the AFO.
B. Finding of Fact No. 46.
Finding of Fact No. 46 reads:
Despite the SOAH ALJs finding Dr. Nazari’s testimony to be credible,
Dr. Nazari did not properly follow Medicaid policy in his identification
of ectopic eruptions; the overwhelming evidence of the consistent
pattern of inflated HLD scores submitted by ADC establishes prima
facie evidence that is reliable, relevant and material that ADC‘s
misrepresentations of medical necessity constitute willful
misrepresentations.
As proposed by the ALJs FoF No. 46 stated: Dr. Nazari was a credible
witness and properly utilized the Manuals’ definition in scoring the HLD index.
Finding of Fact No. 46 is a legislative finding because it is founded on the
(erroneous) presumption that Texas Medicaid policy incorporates a special
definition for ectopic eruption. The ALJs’ proposed finding had two components:
(1) Medicaid had a special definition for ectopic eruption; and (2) Dr. Nazari
properly followed Medicaid policy in scoring his patients. Neither element is
accurate.
The EC modified the ALJs’ proposed FoF No. 46 because the ALJs relied
on the faulty proposition that Medicaid adopted a special definition for ectopic
eruption. Further, Dr. Nazari’s testimony reveals that he did not properly apply
Medicaid policy to the scoring of his patients. Vol. 4, at 103:13-16, 104:1-4, 145:9-
51
10, A.R. at 2731-32, 2773, where Dr. Nazari testified that orthodontics for
Medicaid patients is different than orthodontics for non- Medicaid patients.47
Further, Dr. Nazari was unable to define a “severe handicapping malocclusion.”
Id., at 144:17-145:6, A.R. at 2772-73. The EC fully explained his reasons for
modifying FoF No. 46. See App. A, at pp. 23-24, A.R. at 1766-67. This provides
the substantial evidence needed to support the AFO. Antoine cannot establish a
lack of substantial evidence on the part of the EC, and consequently, the Court
should affirm the AFO.
C. Finding of Fact No. 47.
Finding of Fact No. 47 reads:
Despite the SOAH ALJs finding Dr. Kanaan’s testimony to be credible,
Dr. Kanaan did not properly follow Medicaid policy in his identification
of ectopic eruptions; the overwhelming evidence of the consistent
pattern of inflated HLD scores submitted by ADC establishes prima
facie evidence that is reliable, relevant and material that ADC‘s
misrepresentations of medical necessity constitute willful
misrepresentations.
As proposed by the ALJs FoF No. 23 stated: Wael Kanaan, D.D.S. an
orthodontist who worked with ADC was a credible witness and properly utilized
the Manuals’ definition of ectopic eruption in scoring the HLD index.
Finding of Fact No. 47 is a legislative finding because it is founded on the
47
In this regard, Dr. Nazari’s testimony differed from Dr. Kanaan’s. Dr. Kanaan testified that
Medicaid patients and non-Medicaid patients should be diagnosed and treated to the same
standard; yet, in practice he did not follow that guidance. See supra note 40.
52
(erroneous) presumption that Texas Medicaid policy incorporates a special
definition for ectopic eruption. The ALJs’ proposed finding had two components:
(1) Medicaid had a special definition for ectopic eruption; and (2) Dr. Kanaan
properly followed Medicaid policy in scoring his patients. Neither element is
accurate.
First, the EC corrected the ALJs’ error of law regarding Medicaid policy.
Then, he appropriately applied the law to the facts in the record. In their PFD, the
ALJs acknowledged that Dr. Kanaan scored 23 of 27 patients exactly the same
way—with the same eight teeth being scored as ectopic in all 23 patients. PFD at
p.25, A.R. at 1219. Although they recognized this pattern by Dr. Kanaan, the ALJs
failed to correctly apply the law to the facts. Dr. Kanaan’s approach to Medicaid
patients, at the very least, indicates that Dr. Kanaan was reckless in his scoring, or
indifferent to the actual standards for qualifying a Medicaid patient. Dr. Kanaan’s
scoring 23 out of 27 patients exactly the same way constitutes prima facie evidence
that he acted with the requisite scienter to commit fraud or willful
misrepresentations. See Tex. Hum. Res. Code § 36.0011(b), defining Culpable
Mental State:
A person acts knowingly with respect to information if the person:
(1) has knowledge of the information;
(2) acts with conscious indifference to the truth or falsity of the
information; or
(3) acts in reckless disregard of the truth or falsity of the
53
information. Tex. Hum. Res. Code § 36.0011(a).
In his AFO the EC fully explained the reasons for his changes to FoF No.
47. See App. A, at pp. 24-26, A.R. at 1767-69. This provides the substantial
evidence needed to support the AFO. Antoine cannot establish a lack of
substantial evidence on the part of the EC, and consequently, the Court should
affirm the AFO.
D. Finding of Fact No. 48.
Finding of Fact No. 48 reads:
HHSC-OIG presented evidence that is credible, reliable, and verified,
and that has indicia of reliability when analyzed consistently with Texas
law and Medicaid policy, that ADC knowingly incorrectly scored the
HLD index on orthodontic prior approval requests submitted to Texas
Medicaid.
As proposed by the ALJs, FoF No. 48 stated: There is no evidence that is
credible, reliable, or verifiable, or that has indicia of reliability, that ADC
incorrectly scored the HLD Index to obtain Texas Medicaid benefits for patients
or to obtain Texas Medicaid payments.
The EC was authorized to change FoF No. 48 because it is a mixed finding
of fact and law. The finding incorporates two components: (1) a statement
regarding whether Antoine properly scored the HLD index (“There is no evidence
. . . that ADC incorrectly scored the HLD . . .”); and (2) a statement regarding
Antoine’s intent (“. . . to obtain Texas Medicaid benefits for parents or to obtain
54
Texas Medicaid benefits.”). As to both components, the ALJs’ proposed finding
reflected a misunderstanding of: (a) Texas Medicaid policy; (b) the OIG’s burden
of proof in a payment hold proceeding; and (c) the standard for proving scienter
under the TMFPA.
In contravention of HHSC policy, the ALJs erroneously determined that
Texas Medicaid adopted a liberal interpretation of Medicaid policy with respect
to ascertaining whether a patient exhibits ectopic eruption. Upon accepting the
“anything goes” standard propounded by Drs. Orr, Nazari and Kanaan, the ALJs
then found no error, much less a willful error in Antoine’s scoring. The lynch-pin
to this finding was the ALJs’ misunderstanding, and misapplication, of the limits
of Texas Medicaid’s orthodontia policy. The ALJs compounded their error by
misapplying Texas law: specifically, the ALJs misapplied the OIG’s burden of
proof at the proceeding, and they ignored the TMFPA standard for scienter of
conscious indifference or reckless disregard. See Tex. Hum. Res. Code §
36.0011(a).
At the payment hold hearing, the OIG bore the burden of presenting prima
facie evidence of fraud or willful misconduct. Prima facie evidence is “evidence
that, until its effect is overcome by other evidence, will suffice as proof of a fact
in issue.” Rehak Creative Servs. v. Witt, 404 S.W.3d 716, 726 (Tex. App.—
Houston [l4th Dist.] 2013, pet. denied). The OIG satisfied its burden by presenting
55
evidence of Antoine’s scoring pattern for the HLD scoresheets. See R-49, Tadlock
summary, at A.R. 1097-98, App. I. Section 36.0011 of the TMFPA, as noted
supra, defines the culpable mental state the State must establish to prove unlawful
acts. The State must show the person acted with knowledge of the truth or falsity
of information; or with conscious indifference to the truth or falsity of the
information; or with reckless disregard of the truth or falsity. Tex. Gov’t Code §
36.0011(a). Importantly, the State is not required to show the person’s specific
intent to commit an unlawful act. Id., § 36.0011(b).
Therefore, in correctly applying Medicaid policy and Texas law to the
evidence, the EC was fully authorized to correct the ALJs’ erroneous finding: (1)
that there was not credible, reliable, verified evidence with indicia of reliability
that Antoine incorrectly scored HLD indices; (2) that there was no evidence
Antoine did so for the purpose of obtaining Medicaid benefits.
As required by law, the EC fully explained the rationale for his changes. See
App. A, at pp. 26-28, A.R. at 1769-71. This explanation provides the substantial
evidence needed to support the AFO. Antoine cannot establish a lack of
substantial evidence on the part of the EC, and consequently, the Court should
affirm the AFO.
E. Finding of Fact No. 49.
Finding of Fact No. 49 reads:
56
HHSC-OIG presented prima facie evidence that is credible, reliable,
and verified, and that has indicia of reliability when analyzed
consistently with Texas law and Medicaid policy, that [Antoine]
committed fraud or willful misrepresentations to Texas Medicaid.
As proposed by the ALJs, FoF No. 49 stated: There is no evidence that is credible,
reliable, or verifiable, or that has indicia of reliability, that [Antoine] committed
fraud or engaged in willful misrepresentation with respect to the 63 [Antoine]
patients in this case.
The EC was authorized to change FoF No. 49 because it is a mixed finding
of fact and law. The ALJs’ proposed finding incorporated their misunderstanding
of Medicaid policy, and misapplication of Texas law, to the evidence. The EC
explained the reasons for his changes to FoF No. 49. See App. A, at pp. 28-30,
A.R. at 1771-73. This explanation provides the substantial evidence needed to
support the AFO. Antoine cannot establish a lack of substantial evidence on the
part of the EC, and consequently, the Court should affirm the AFO.
F. Finding of Fact No. 50.
Finding of Fact No. 50 reads:
HHSC-OIG presented prima facie evidence that is credible, reliable, and
verified, and that has indicia of reliability when analyzed consistently
with Texas law and Medicaid policy, that ADC committed fraud or
wilful misrepresentations in filing requests for prior authorization with
TMHP for a substantial majority of patients in the OIG audit sample.
As proposed by the ALJs, FoF No. 50 stated: There is no evidence that is credible,
57
reliable, or verifiable, or that has indicia of reliability, that ADC committed fraud
or misrepresentation in filing requests for prior authorization with TMHP for the
63 patients at issue in this case.
The EC was authorized to change FoF No. 50 because it is a mixed finding
of fact and law. The ALJs’ proposed finding incorporated their misunderstanding
of Medicaid policy, and misapplication of Texas law, to the evidence. As with FoF
No. 49, the EC explained the rationale for his changes. See App. A, at pp. 30-31,
A.R. at 1773-74. This explanation provides the substantial evidence needed to
support the AFO. Antoine cannot establish a lack of substantial evidence on the
part of the EC, and consequently, t the Court should affirm the AFO.
G. Conclusion of Law No. 13.
Conclusion of Law No. 13 in the AFO reads:
HHSC-OIG should maintain the payment hold against ADC for
alleged fraud or willful misrepresentation, and program
violations. Tex. Gov’t Code § 531.102(g) (2011); 42 CFR § 455.23
(2011); Tex. Hum. Res. Code § 32.091(c) (2003); 1Tex. Admin.
Code §§ 371.1703(b)(3), and (b)(5), 371.1617(a)(1)(A)-(C), (I),
(K), (2)(A), (5)(A), (5)(G) (2005).
As proposed by the ALJs, CoL No. 13 stated: HHSC-OIG lacks authority to
maintain the payment hold against ADC for alleged fraud or misrepresentation.
Tex. Gov’t Code § 531.102(g) (2011); 42 CFR § 455.23 (2011); Tex. Hum. Res.
Code § 32.091(c) (2003); 1 Tex. Admin. Code §§371.1703(b)(3),
371.1617(a)(1)(A)-(C) (2005).)
58
The EC was authorized to change CoL No. 13 because it was a pure question
of law committed to the discretion of the agency. Further, to the extent that CoL
No. 13 was actually a recommendation from the ALJs, and not a true conclusion
of law, the EC was fully authorized to modify it. See Granek v. Texas State Bd. of
Med. Exam'rs, 172 S.W.3d 761, 781 (Tex. App.—Austin 2005, no pet.); Akin,
2015 WL 1611803, *5; see also Pierce v. Tex. Racing Comm’n, 212 S.W.3d at
754 n.7 (“We need not decide, however, whether the ALJ had authority to
recommend a penalty in a racing commission case because, regardless of whether
the ALJ's conclusion of law was authorized, the Commission was statutorily
authorized to modify or reject it.” (citing Tex. Gov't Code § 2001.058(e))).
As required by the APA and black letter Texas law, the EC fully
explained the reasons for his change to CoL No. 13. See App. A, at pp. 39-40, A.R.
at 1782-83. This explanation provides the substantial evidence needed to support
the AFO. Antoine cannot establish a lack of substantial evidence on the part of the
EC, and consequently, the Court should affirm the AFO.
PRAYER
WHEREFORE, the State prays that the Court find that the AFO is fully
supported by substantial evidence, and the EC did not exceed his authority in
entering the AFO. The State respectfully prays that this Court reverse the
honorable district court and affirm the EC’s AFO in all respects.
59
Respectfully submitted,
OFFICE OF THE ATTORNEY GENERAL
CHARLES E. ROY
First Assistant Attorney General
JAMES E. DAVIS
Deputy Attorney General for Civil Litigation
/s/ Raymond C. Winter
RAYMOND C. WINTER
Chief, Civil Medicaid Fraud
Division State Bar No. 21791950
Phone: (512) 936-1709
Fax: (512) 370-9477
raymond.winter@texasattorneygeneral.gov
REYNOLDS B. BRISSENDEN
State Bar No. 24056969
reynolds.brissenden@texasattorneygeneral.gov
Phone: (512) 936-2158
NOAH REINSTEIN
State Bar No. 24089769
noah.reinstein@texasattorneygeneral.gov
Phone: (512) 463-3457
Assistant Attorneys General
Office of the Attorney General of
Texas Civil Medicaid Fraud Division
P.O. Box 12548, Capitol Station
Austin, Texas 78711-2548
ATTORNEYS FOR TEXAS HEALTH
AND HUMAN SERVICES COMMISSION
AND OFFICE OF THE INSPECTOR
GENERAL
60
CERTIFICATE OF COMPLIANCE
I certify pursuant to Tex. R. App. P. 9.4(i) that this Brief, excluding the: caption,
identity of parties and counsel, statement regarding oral argument, table of
contents, index of authorities, statement of the case, statement of issues presented,
signature, proof of service, certification, certificate of compliance, and appendix
has 14,450 words. This Brief was prepared using Microsoft Word 2010 and I have
relied on the word count from that program.
/s/ Raymond C. Winter
Raymond C. Winter
CERTIFICATE OF SERVICE
I certify that I have on this the 9th day of November, 2015, served copies of
this Appellant’s Brief to the following:
Jason Ray J.A. “Tony” Canales
Riggs & Ray, PC Canales & Simonson, PC
506 W. 14th Street, Suite A 2601 Morgan Avenue
Austin, Texas 78701 P.O. Box 5624
jray@r-alaw.com Corpus Christi, Texas 78465
tonycanales@canalessimonson.com
/s/ Raymond C. Winter
Raymond C. Winter
61
INDEX OF APPENDIX
APPENDIX A Amended Final Order
APPENDIX B Medicaid.gov Website, Statistics
APPENDIX C Excerpts from Tex. Medicaid and CHIP in Perspective, 10th
Ed., Feb. 2015
APPENDIX D 2011 Tex. Medicaid Provider Procedures Manual - Excerpts
APPENDIX E 2010 Tex. Medicaid Provider Procedures Manual - Excerpts
APPENDIX F 2009 Tex. Medicaid Provider Procedures Manual - Excerpts
APPENDIX G 2008 Tex. Medicaid Provider Procedures Manual – Excerpts
APPENDIX H Exhibit R-51. Prevalence of malocclusion and orthodontic
treatment need in children and adolescents in Bogota,
Colombia. An epidemiological study related to different states
of dental development. Birgit Thilander, 2001, European J. of
Orthodontics.
APPENDIX I Spreadsheet of dental scores submitted by Antoine
APPENDIX J Exhibit R-88. HHSC-OIG’s Proffer of Rebuttal Testimony
from Dr. Linda Altenhoff
62
Append¡x A
II32
„iˆeƒ2riev„r2exh2r…wex2ƒi‚†sgiƒ2gywwsƒƒsyx2
u‰vi2vF2texiuD2whF2
iˆig…„s†i2gywwsƒƒsyxi‚2
w—y2PD2PHIR2
DP2
“„ony”2g—n—les2
tF2 eF2 EF2
ƒteven2tohnson2 iv’X2
g—n—les282ƒimonson2 esso™i—te2gounsel2 Q2‘BS2
PTHI2worg—n2evenue2 EIPDD2
yffi™e2of2snspe™tor2qener—l2 PU2I9I‘Y2if2
€2y2fox2STPR2 €2y2fox2VSPHHD2wgX2IQSEV2 —t2
„42
pE2
gorpus2ghristiD2„ex—s2UVRTS2
DE2
eustinD2„ex—s2UVUHVESPHH2 weEI7X2
»~2g 92
EF92•2E“tY2 FF2
EB4njF2
h—n2r—rgrove2 t—son2hF2‚—y2 I»2rX2
DF2
‡—ters282ur—usD2vv€2
htc
‘2
‚iggsD2eleshireD2‚—yD2€FgF2
QPIW2w™uinney2evenue2 UHH2v—v—™—D2ƒuite2WPHH2
IFI2
h—ll—sD2„ex—s2USPHI2 eustinD2„ex—s2UVUHI2
t—mes2wori—rty2 „hom—s2rF2‡—tkins2
wori—rty2veyende™kerD2€g2 rus™h2fl—™kwell2
RIIW2wontrose2flvdD2ƒuite2PSH2 III2gongress2evenueD2ƒuite2IRHH2
roustonD2„ex—s2UUHHT2 eustinD2„ex—s2UVUHI2
‚—ymond2gF2‡inter2
givil2wedi™—id2pr—ud2hivision2
yffi™e2of2ettorney2qener—l2
€2y2fox2IPSRV2
eustinD2„ex—s2UVUIIEPSRV2
qentlemenX2
in™losed2is2the2signed2—mended2pin—l2yrder2in2entoine2hent—l2
g—re2vF2 „ex—s2re—lth2—nd2rum—n2
ƒervi™es2gommissionD2yfli™e2of2snspe™tor2qener—lD2rrƒgEysq2 g—se2xoF2€PHI2IIQITSPQVRVWIF2
ƒin™erelyD2
URGGIE2
ghris2„r—ylor2
ghief2heputy2gommissioner2
€F2 yF2fox2IQPRU2 v2 eustinD2„ex—s2 UVUII2 H2 RWHHxorth2v—m—rD2eustinD2„ex—s2 UVUSI2 H2 @SIPARPRETSHH
001743
ƒyer2hygui„2xyF2SPWIQHWWU2
rrƒg2e€€ievƒ2hs†sƒsyx2xyF2sQEHHQWEu2
rrƒgEysq2geƒi2xyFX2€PHIIIQITSPQVRVWI2
ex„ysxi2hix„ev2gix„i‚D2 fipy‚i2„ri2
€etitioner2
vF2 „iˆeƒ2 riev„r2 exh2 r…wex2
ƒi‚†sgiƒ2gywwsƒƒsyx2
„iˆeƒ2riev„r282r…wex2 e€€ievƒ2hs†sƒsyx2
ƒi‚†sgiƒ2gywwsƒƒsyxD2yppsgi2
yp2sxƒ€ig„y‚2qixi‚evD2
‚espondent2
ewixhih2psxev2y‚hi‚2
yn2this2 •f••2 d—y2of2 €fiYtaXi~F~F»F2
D2 PHIRD2 ™—me2to2 ˜e2™onsidered2 the2 —˜oveE2
styled2™—se2˜efore2the2ixe™utive2gommissioner2of2the2„ex—s2re—lth2—nd2
rum—n2ƒervi™es2
gommission2@rsEsƒgAF2
fefore2the2ixe™utive2gommissioner2—reX2 the2€ropos—l2for2he™ision2
@€phA2issued2
˜y2the2ƒyer2evts2row—rd2ƒF2 ƒeitzm—n2—nd2g—therine2gF2 ig—n2@“ƒyer2evts”AD2d—ted2
xovem˜er2RD2 PHIQY2the2snspe™tor2qener—l‘s2ix™eptions2to2the2€phD2d—ted2xovem˜er2
PPD2
PHIQY2the2‚esponse2to2the2snspe™tor2qenerzIl’s2ix™eptions2filed2 entoine2
˜y2 hent—l2genter2
@“ehg”AD2d—ted2he™em˜er2TD2 PHIQY2the2ƒyer2evts’2letter2 —mending2
their2€phD2d—ted2
t—nu—ry2lTD2PHIRY2the2first2pin—l2yrder2issued2˜y2rrƒg2evt2‚i™k2qilpinD2d—ted2
pe˜ru—ry2
PUD2PHlRY2the2wotion2for2‚ehe—ring2filed2with2rrƒg2 the2yffi™e2
˜y2 of2snspe™tor2qener—lD2
d—ted2epril2 PD2 PHIRY2—nd2the2re™ord2in2 the2 ™—se2—t2 ƒyerF2 ƒee2
„exF2 qov’t2 gode2ennF2
§§2PHHIFHTHD2PHHIFHTP2@‡est2PHIQAF2
yn2pe˜ru—ry2PUD2PHIRD2—fter2™onsider—tion2of2the2€phD2the2ple—dings2of2the2p—rties2
—nd2re™ordD2 the2 rrƒgEevt2issued2 —2 pin—l2 yrder2in2 this2 ™—seF2 „he2rrƒgEevt2
served2
noti™e2of2the2pin—l2yrder2on2—ll2 p—rties2 ˜y2letter2d—ted2w—r™h2
IPD2 PHIRF2 ƒee2„exF2qov’t2
gode2§2PHHlFlRP@˜A2@requiring2—2st—te2—gen™y2to2serve2—2p—rty2with2—2
™opy2of2—n2order2th—t2
m—y2˜e™ome2fin—l2first2™l—ss2m—ilAF2yn2epril2PD2PHIRD2the2snspe™tor2qener—l2filed2—2 timely2
wotion2for2‚ehe—ring2with2the2rrƒg2eppe—ls2hivisionF2 „exF2qov’t2
gode2§2cFHHlFIRT@—A2
@requiring2 —2 p—rty2 to2 file2 —2 motion2 for2 rehe—ring2 within2
twenty2 d—ys2 —fter2 the2 p—rty2
re™eives2noti™e2of2—n2order2th—t2m—y2˜e™ome2fin—lAF
s
001744
elter2™onsidering2the2—ddition—l2—rguments2r—ised2in2the2wotion2for2‚ehe—ringD2—nd2
in2—™™ord—n™e2with2„exF2qov’t2gode2 PHHlFHSV@eAD2the2ixe™utive2gommissioner2
§2 issues2
this2emended2pin—l2yrderF2
„he2ixe™utive2gommissioner2finds2th—t2the2ƒyer2evt2s2did2not2properly2—pply2or2
interpret2—ppli™—˜le2„ex—s2wedi™—id2poli™y2—nd2—ppli™—˜le2l—ws2governing2
the2wedi™—id2
progr—m2—nd2this2pro™eedingF2„exF2qov’t2gode2§2PHHlFHSV@eA@lAF2
ƒpe™ifi™—llyD2 the2 ixe™utive2 gommissioner2finds2 th—t2 the2 ƒyer2esFts2 erred2 in2
interpreting2 „ex—s2wedi™—id2poli™y2 —s2 —llowing2 wedi™—id2providers2 to2
—pply2—2 spe™i—l2
interpret—tion2 to2 the2 me—ning2 of2 the2 phr—se2 4e™topi™2 eruptionF”2 „he2 ƒyer2
evts92
determin—tion2th—t2 e™topi™2eruption2h—s2—2spe™i—l2me—ning2for2the2purposes2of2wedi™—id2
eligi˜ility2th—t2is2 different2fromD2—nd2more2li˜er—l2th—nD2the2interpret—tion2of2the2
phr—se2in2
the2 gener—l2 pr—™ti™e2 of2dentistry2 ™ontr—venes2 „ex—s2 wedi™—id2
poli™y2 —nd2„ex—s2 —nd2
feder—l2l—wF2ƒeeD2 eFgFD2 PS2„exF2edminF2gode2 QQFUl@—A2@PHHVA2@yrthodonti™2
§2 ƒervi™es2—nd2
€rior2euthoriz—tionA2 @providing2th—t2 wedie—id’s2oithodonti—2˜enelit2 is2 limited2
to2 ™—ses2
presenting2severe2h—ndi™—pping2m—lo™™lusionAY2see2—lso2ixF2‚EsRF2PHHV2„w€€wD2
§2 IFPFSD2
gompli—n™e2with2peder—l2 vegisl—tion2 @m—nd—ting2th—t2 providers2 must2“furnish2 ™overed2
wedi™—id2servi™es2 in2 the2 s—me2m—nnerD2to2 the2 s—me2extentF2 —nd2of2the2 s—me2qu—lity2—s2
servi™es2 provided2 to2 other2 p—tients4AF2 „he2 ƒyer2evts2 mis—pplied2
—ppli™—˜le2 l—wD2
—gen™y2rulesD2 —nd2poli™iesD2—nd2then2misinterpreted2the2testimony2of2‡itnesses2reg—rding2
the2 limit—tions2 ol’2wedi™—id2poli™y2—nd2reg—rding2the2 me—ning2oi’2 e™topi™2
eruptionF2 ƒee2
„exF2qov’t2gode2§2 PHHlFySV@eA@lAY2ƒyvtll‡€Fƒ9l€lIltl’sU’sF2 ƒolutionsD2sn™F2 vF2 „exF2
rrƒgD2RHV2
ƒF‡FQd2SRWD2STP2@„exF2eppF~eustin2PHIQD2petF2 deniedA2@“es2the2 —gen™y2design—ted2to2
—dminister2wedi™—idD2rrƒg2is2 ™h—rged2with2overseeing2—2 ™omplex2regul—tory2
s™hemeD2
—nd2deferen™e2to2 its2 ™onstru™tion2is2 p—rti™ul—rly2import—ntF”2@™iting2‚F‚F2 gomm n2vF2 ‘2
„exF2
gitizensGor2—2ƒ™gfé2puture282gle—n2‡—terD2QQT2ƒF‡FQd2TIWD2TPW2@„exF2PHI2
IAAF2
„he2ixe™utive2gommissioner2further2finds2th—t2the2ƒyer2evts2erred2to2the2extent2
th—t2they2impermissi˜ly2misinterpreted2—nd2mis—pplied2—ppli™—˜le2
l—wD2rulesD2 —nd2poli™y2
whi™h2resulted2in2 wrongly2dismissing2prim—2fiz™ie2eviden™e2th—t2s—tisfies2the2evidenti—ry2
requirements2to2 m—int—in2—2p—yment2holdF2 ƒee2„exF2qov‘t2gode2
§2 PHHlFHSV@eA@lAF2 „he2
ixe™utive2 gommissioner2finds2th—t2 the2 snspe™tor2 qener—l2presented2relev—ntD2 ™redi˜leD2
—nd2m—teri—l2 eviden™e2th—t2 ehg2su˜mitted2 fr—udulent2or2willfully2 misrepresented2prior2
—uthoriz—tion2requests2—nd2™l—ims2for2reim˜ursementY2 ehg2su˜mitted2™l—ims2for2servi™es2
not2reim˜urs—˜leY2—nd2ehg2f—iled2to2m—int—in2or2provide2re™ords2—s2required2˜y2l—wF2
„he2ixe™utive2gommissioner2further2finds2th—t2the2ƒyer2evts2erred2to2the2extent2
th—t2 they2relied2 on2™ert—in2 findings2 of2f—™t2 in2 l—Ess»Esƒg92s2 tin—l2 order2in2
r—rlingen2p—Gnily2
hent—l2vF2 „ex—s2re—lth2—nd2rum—n2ƒervi™es2gl92onIGnlssfonD2 y‘Gfi™e2 snspe™tor2qener—lF2
of2
9U
F
001745
ƒee2yrder2signed2˜y2rrƒgEevt2ƒF2 x—sh2peketyD2d—ted2t—nF2 UD2 PHIQD2in2 rrƒg2eppe—ls2
hivisionD2 g—use2 xoF2 IP~HUVWEuF2 „he2 ixe™utive2 gommissioner2 h—s2 detemiined2 th—t2
™ert—in2 ol’2 the2 findings2 in2 the2r—rlingen2p—mily2hent—l2™—se2 in™orre™tly2 st—ted2 the2 l—wD2
rulesD2 —nd2wedi™—id2poli™y2—nd2™—nnot2˜e2relied2on2in2this2 ™—seF2ƒee2„exF2 qov’t2gode §2
PHHIFHS2V@eA@PAF2ƒpe™ifi™—llyD2the2ixe™utive2gommissioner2™on™ludes2th—t2pinding2of2p—™t2
xoF2PW2in2the2r—rlingen2p—mily2hent—l2™—se2w—s2erroneous2to2the2extent2th—t2it2 suggested2
th—t2the2snspe™tor2qener—l’s2ret—ined2expert2hrF2gh—rles2iv—ns2w—s2not2qu—lified2to2 ˜e2—n2
expert2˜e™—use2he2did2not2tre—t2wedi™—id2p—tientsF2„h—t2finding2w—s2erroneous2—nd2™—nnot2
˜e2relied2on2in2this2 ™—se2˜e™—use2ƒt—te2 —nd2feder—l2l—ws2require2wedi™—id2p—tients2to2 ˜e2
tre—ted2to2 the2 s—me2st—nd—rd2of2™—re2 —s2p—tients2 in2 the2 gener—l2popul—tionF2 ƒeeD2 eDgFD2 PS2
„exF2edminF2gode2§2 QQFUl@—A2@providing2th—t2wedi™—id’s2oithodonti—2˜enefit2is2 limited2to2
™—ses2presenting2severe2h—ndi™—pping2m—lo™™lusionAY2see2—lso2ixF2‚ElRD2PHHV2„w€€wD §2
IFPFSD2 gompli—n™e2 with2 peder—l2 vegisl—tion2 @m—nd—ting2 th—t2 providers2 must2 “furnish2
™overed2 wedi™—id2servi™es2 in2 the2 s—me2m—nnerD2 to2 the2 s—me2extentD2 —nd2 of2the2 s—me2
qu—lity2—s2servi™es2provided2to2other2p—tients4AF2 e™™ordinglyD2the2f—™t2th—t2hrF2iv—ns2did2
not2 tre—t2 wedi™—id2p—tients2 in2 his2 pr—™ti™e2 m—y2not2 ˜e2used2in2 properly2 ev—lu—ting2 his2
qu—lifi™—tions2@skillD2knowledgeD2experien™eD2—nd2tr—iningA2—s2—n2expert2in2this2™—seF2„o2the2
extent2th—t2 the2 ƒyer2evts2in2 the2 inst—nt2™—se2relied2 on2pinding2of2p—™t2xoF2PW2 from2
r—rlingen2in2their2—n—lysis2of2this2™—se2—nd2of2hrF2iv—nsD2they2erredF2
sn2 —dditionD2 pinding2 of2 p—™t2 xoF2 QI2 in2 the2 r—rlingen2 p—mily2 hent—l2 ™—se2
erroneously2 st—ted2 —nd2—pplied2 „ex—s2l—w2—nd2wedi™—id2poli™yD2 to2 the2 extent2 th—t2 the2
finding2 suggested2 wedi™—id2poli™y2 interprets2 “e™topi™2 eruption”2 differently2 —nd2more2
exp—nsively2@or2more2li˜er—llyA2th—n2the2™ondition2is2 interpreted2in2the2gener—l2pr—™ti™e2of2
dentistryF2 es2noted2 —˜oveD2 the2r—rlingen2p—mily2hent—l2de™ision2—pplied2the2 l—w2—nd2
poli™y2 erroneously2 —nd2 ™—nnot2 ˜e2 relied2 on2 in2 this2 ™—seF2 „exF2 qov’t2 gode2
§2PH@AlF@ASV@eA@PAF2
r—rlingen2p—mily2hent—l2pinding2of2p2—™t2xoF2QQ2w—s2—lso2erroneous2to2the2extent2
th—t2it2 expl—ined2—w—y2eviden™e2of2fr—ud2˜y2impermissi˜ly2™l—iming2hrF2iv—ns2w—s2not —2
qu—lified2expert2witnessF2 „he2r—rlingen2p—mily2hent—l2ev“2opined2th—t2 hrF2 iv—ns2h—s2
not2tre—ted2wedi™—id2p—tients2 in2 his2priv—te2pr—™ti™e2—nd2th—t2hrF2iv—ns2s™ored2the2rvh2
indi™es2 in2 the2 r—rlingen2 p—mily2 hent—l2 s—mple2 in2 —™™ord—n™e2 with2 the2 ™ommon2
interpret—tion2 in2 the2 gener—l2 pr—™ti™e2 of2dentistryF2 —s2 opposed2to2 the2 “more2exp—nsive42
interpret—tion2 th—t2 the2 r—rlingen2 p—mily2hent—l2 ev“2 erroneously2 ™l—imed2 h—d2 ˜een2
—dopted2˜y2 rrƒgF2„husD2 ˜e™—use2 the2 r—rlingen2 p—mily2hent—l2evt2relied2 on2these2
f—ulty2premisesD2r—rlingen2p—mily2hent—l2pinding2of2p—™t2xoF2QQ2w—s2—2mis—ppli™—tion2of
Q
001746
l—wF2 „o2the2extent2th—t2the2ƒyesEs2esFFts2 relied2on2the2r—rlingen2p—mily2hent—l2™—se2for2
their2underst—nding2of2wedi™—id2poli™yD2they2erredF2 sdF2
„he2ixe™utive2gommissioner2expressly2dis—pproves2ol’2r—rlingen2p—mily2hent—l2
pindings2of2p—™t2xosF2 PWD2 QID2 —nd2QQ2 —nd2de™l—res2th—t2these2findings2were2in™orre™tly2
de™ided2—nd2should2not2˜e2relied2on2in2 this2™—se2or2—ny2other2™—seF2ƒee2„exF2qov’t2gode
§2
PHHlFHSV@eA@PA2 @—uthorizing2 —n2 —gen™y2 to2 modify2 —2 €ph2when2 it2 relies2 on2 —2 prior2
—dministr—tive2de™ision2th—t2is2“in™orre™t2or2should2˜e2™h—nged”AF2
„he2 ixe™utive2 gommissioner2 —lso2 finds2 th—t2 the2 ƒyer2evtƒ2 f—iled2 to2 ˜oth2
properly2—rti™ul—te2—nd2then2properly2—pply2the2snspe™tor2qener—l92s2evidenti—ry2˜urden2to2
the2eviden™e2presentedF2 sn2 order2to2 m—int—in2the2p—yment2holdD2the2snspe™tor2
qener—l2is2
required2to2 present2prim—2f—™ie2 eviden™e2th—t2 is2 relev—ntD2 ™redi˜leD2 —nd2m—teri—l2
to2 the2
issue2 of2 fr—ud2 or2 willful2 misrepresent—tionD2 or2 prim—2f—™ie2 eviden™e2
th—t2 ehg2 h—s2
™ommitted2otherD2 nonEfr—udulent2progr—m2viol—tionsF2 ƒee2„exF2ssumF2 ‚esF2 gode2ennF
§2
QPFHPWl@™A2@†ernon2PHHQA2@—mended2PHIQA2@“„he2dep—rtment2sh—ll2 dis™ontinue2the2 hold2
unless2 the2 dep—rtment2m—kes2—2priGn—2f—eie2 showing2—t2 the2 he—ring2th—t2 the2
eviden™e2
relied2on2˜y2the2dep—rtment2in2imposing2the2hold2is2relev—ntD2 ™redi˜leD2—nd2m—teri—l2
to2the2
issue2ofXGr—ud2Hr2wilful2misrepresent—tionF”A2@emph—sis2—ddedAY2see2—lso2„exF2qov4t2
gode2
§2 SQlFlHP@gA@PA2 @“the2 ‘snspe™tor2qener—l“2 sh—ll2 impose2without2prior2noti™e2 —2p—yment2
hold2on2™l—ims2for2reim˜ursement2su˜mitted2˜y2—2provider2 on2the2determin—tion2th—t —2
F2 F2 F2
™redi˜le2 —lleg—tion2 of2fr—ud2 exists“AY2 RP2gFpF‚F2 RSSFPQ2 @“„he2ƒt—te2
§2 wedi™—id2—gen™y2
must2suspend2—ll2 wedi™—id2p—yments2to2—2provider2—lter2the2—gen™y2determines2there2is —2
™redi˜le2 —lleg—tion2 of2fr—ud2 for2 whi™h2—n2 investig—tion2 is2 pending2 under2
the2 wedi™—id2
progr—m2—g—inst2—n2individu—l2or2entity2unless2the2—gen™y2h—s2good2™—use2to2 not2suspend2
p—yments2or2 to2 suspend2p—yment2only2 in2 p—rt4AY2 s2 „exF2 edminF2 gode2 QUlFIUHQ@˜A2
§2
@PHHSA2 @‚e™overy2of2yverp—ymentsA2 @“e2p—yment2hold2on2p—yments2of2puture2 ™l—ims2
su˜mitted2for2reim˜ursement2will2 ˜e2imposedD2without2prior2noti™eD2 —fter2it2 is2 determined2
th—t2prim—2f—™ie2eviden™e2exists2to2support2the2p—yment2hold”AF2
ƒpe™ifi™—llyD2 the2 ixe™utive2 gommissioner2 finds2 th—t2 the2 snspe™tor2 qener—l2
presented2prim—2f—™ie2eviden™e2of2—™ts2 —nd2omissions2˜y2 ehg2
justifying2the2imposition2
of2—2 IHH72p—yment2holdF2—nd2th—t2 ehg2f—iled2 to2re˜ut2su™h2eviden™eF2 „exF2 rumF2‚esF2
gode2§2QPFHPWl@™AY2„exF2qov4t2gode2§2SQIFlHP@gA@PAY2RP2gFpF‚F2 RSSFPQF2
§2
„he2ixe™utive2gommissioner2finds2th—t2when2wedi™—id2poli™y2—nd2„ex—s2l—ws2—re2
properly2interpreted2—nd2properly2—pplied2to2the2f—™ts2of2re™ord2in2this2 ™—se2the2snspe™tor2
qener—l2h—s2met2his2 evidenti—ry2˜urden2to2 m—int—in2—2 IHH72p—yment2holdF2
sndeedD2the2
ixe™utive2gommissioner2finds2th—t2—2 IHH72p—yment2hold2is2 required2 l—wF2„exF2
˜y2 srsumF2
‚esF2gode2§2 QPFHPWl@™AY2„exF2qov9t2gode2§2SQIFIHP@gA@PAY2RP2gFpF‚F2 RSSFPQF2
§2
por2these2re—sonsD2the2ixe™utive2gommissioner2de™lines2to2—dopt2the2ƒyess2evts’2
proposed2findings2 of2f—™t2 sHD2 PID2 PTD2 PWD2 QWERPD2 RPD2 RRESHD2 SRESSD2 SUD2 —nd2proposed2
™on™lusions2of2l—w2RD2 IHD2 IQD2 IRD2 —nd2ITF2 snste—dD2the2ixe™utive2gommissioner2
linds2th—t
R
001747
the2 inspe™tor2 qener—l’s2 ix™eptions2 h—ve2 merit2 —nd2 should2 ˜e2 gr—ntedF2
purtherD2 the2
ixe™utive2gommissioner2determines2th—t2the2inspe™tor2qener—l’s2p—yment2hold2should2˜e2
m—int—ined2—t2 lH@A7F2
lt2 is2 now2therefore2y‚hi‚ih2—s2followsX2
psx2hsxqƒ2yp2peg„2
lF2 fehz—d2x—z—riD2 hFhFƒFD2 h—s2 owned2entoine2 hent—l2 genter2@ehgA2sin™e2 IWWVF2
ehg2h—s2two2dent—l2™lini™s2in2roustonD2„ex—sD2th—t2tre—t2wedi™—id2—nd2priv—te2p—y2
™lientsF2
PF2 fetween2xovem˜er2 ID2 PHHVD2 —nd2 eugust2QID2 PHIID2 ehg2provided2 dent—l2 —nd2
orthodonti™2 servi™es2to2 wedi™—id2p—tients2 —s2 —2„ex—s2wedi™—id2€rovider2
holding2
€rovider2ldentifi™—tion2xosF2IWHSRQPD2PIVUHQID2IWSPTSUD2—nd2HWHVITPFhgF2
QF2 huring2this2 periodD2 ehg2˜illed2„ex—s2wedi™—id2—pproxim—tely26VDIHRDVUSFUS2 for2
orthodonti™2servi™esF2
RF2 ln2PHIHD2—pproxim—tely2UH72ofehg9s2p—tients2were2wedi™—id2p—tientsF2
SF2 „he2feder—l2govemment2—nd2the2ƒt—te2of2„ex—s2sh—re2the2™ost2of2„ex—s2wedi™—idD2
with2the2 feder—l2government2™ontri˜uting2—pproxim—tely2TH72of2the2
p—yments2for2
wedi™—id2servi™esF2
TF2 „he2„ex—s2re—lth2—nd2rum—n2ƒervi™e2gommission2@the2gommissionA2is2the2single2
—gen™y2 responsi˜le2 for2 the2 —dministr—tion2 of2 the2 „ex—s2 wedi™—l2 essist—n™e2
€rogr—m2@„ex—s2wedi™—idA2—nd2does2so2˜y2™ontr—™ting2with2he—lth™—re2providersD2
™l—ims2—dministr—torsD2—nd2other2™ontr—™torsF2
UF2 huring2 the2 times2 in2 question2 in2 this2 ™—seD2 „ex—s2wedi™—id2 re—lth2 €—rtnership2
@„wr€A2w—s2the2™ontr—™ted2„ex—s2wedi™—id2™l—ims2—dministr—torF2
VF2 huring2 —ll2 —ppli™—˜le2 periodsD2 the2 gommission9s2 yffi™e2
of2 snspe™tor2 qener—l2
@rrƒgEysqA2w—s2 responsi˜le2 for2 monitoring2 —nd2 investig—ting2 —lleg—tions2 of2
fr—udD2‡—steD2—nd2—˜use2—sso™i—ted2with2the2„ex—s2wedi™—id2progr—mF2
WF2 es2p—rt2of2the2enrollment2pro™essD2 —2provider2—greed2to2™omply2with2the2terms2of2
the2—nnu—l2„ex—s2wedi™—id2€rovider2€ro™edures2w—nu—l2
@w—nu—lA2—nd2the2˜ulletin2
upd—tes2issued2every2two2monthsF2
IHF2 wedi™—id2orthodonti—2servi™es2—re2limited2to2tre—tment2of2™hildren2—ged2IP2to2
PH2 ye—rs2 with2 severe2 h—ndi™—pping2 m—lo™™lusions2 —nd2 other2 rel—ted2
™onditionsD2unless2—n2exemption2is2expressly2sought2˜y2the2providerF‘2
fy2letter2d—ted2t—nu—ry2 ITD2 PHIRF2the2ƒyer2G’lFts2 replied2to2the2 snspe™tor2qener—l’s2ix™eptions2
s2
—nd2notified2the2ixe™utive2gommissioner2th—t2their2origin—l2proposed2finding2off—™t2
num˜er2lH2should2˜e2
revised2 to2 re—dX2 e™™ording2to2 the2 w—nu—lF2 sGIe2 intent2
of2Ghe2 werli™—id2dent—l2progr—m2w—s2to2provide2
dent—l2™ure2GH2™lients2QHyeurs2G4—ge2oryuungerF2 IB2or2the2re—sons2st—ted2
in2this2emended2pin—l2yrderD2the
S
001748
@„he2 ƒyer2evts’2 proposed2pop2xoF2 lH2 st—tedX2 e™™ording2to2 the2 w—nu—lD2 the2
intent2of2the2 wedi™—id2orthodonti—2progr—m2w—s2to2provide2orthodonti™2
™—re2 to2
™lients2 PH2ye—rs2 of2—ge2 or2younger2with2severe2 h—ndi™—pping2
m—lo™™lusion2 to2
improve2•Gitn™tionF A2
‚e—son2for2gh—ngeX2
„he2proposed2finding2is2 not2simply2—2™—seEspe™ifi™2finding2of2f—™t2th—t2determines2
the2“whoD2‡h—tD2whenD2where2—nd2how”2of2this2™—seF2 ‚—therD2in2purporting2
to2re™ite2
wedi™—id2poli™yD2the2proposed2finding2—ddresses2—2mixed2question2of2f—™t2—nd2l—w2
—nd2is2 —2soE™—lled2“legisl—tive2findingF‘4P2es2su™hD2the2ixe™utive2gommissioner2h—s2
“™omplete2dis™retion”2to2modify2the2proposed2findingF2 „exF2 hept2 vi™ensing
of2 82
‚egul—tion2vF2 „hompsonD2yQEllEHHQITEg†D2PHIQ2 ‡v2QUWIRVTD2 —t2 BT2
@tuly2 IVD2
PHIQF2petF2 filedA2@‘“en2—gen™y2enjoys2™omplete2dis™retion2in2 modifying2—n2evt9s2
findings2—nd2™on™lusions2 when2those2 findings2—nd2™on™lusions2refle™t2—2 l—™k2 HI‘2
underst—nding2or2mis—ppli™—tion2of2the2existing2l—wsD2rulesD2 or2poli™iesF”2@quoting2
ƒmith2 vF2 Fwontem—yorD2 HQE@APEHHRTTEg†D2 P@AHQ2 ‡v2PIRHISWID2 —t2 BPTEPU2 exF2
@„2
G’ppF—eustin2 tune2 IWD2 PHHQD2 no2 petFA2 @emph—sis2 —dded»Y2 „exF2 qov‘t2gode
§2
PHHlFHSV@eA@IAF2
„he2ixe™utive2gommissioner2modifies2proposed2pop2xoF2 IH2˜e™—use2it2 misst—tes2
wedi™—id2poli™yF2ƒee2„exF2qov’t2gode2§2PHHlFHSV@eA@lA2@st—te2—gen™y2m—y2™h—nge2
—2 finding2of2f—™t2 or2 ™on™lusion2 of2l—w2 if2 the2 evt2did2 not2 “properly2
—pply2 or2
interpret2—ppli™—˜le2l—wD2—gen™y2rulesD2 ‘or“2 written2poli™ies”AF2
€roposed2finding2or2
f—™t2num˜er2IH2 misst—tes2„ex—s2wedi™—id2poli™yD2 —s2 ™odified2
in2 PS2„exF2edminF2
gode2§2 QQFUI2 —nd2in2the2„ex—s2wedi™—id2€rovider2€ro™edures2w—nu—l2@„I’Gs€€wAF2
es2™odified2in2PS2„exF2edminF2gode2§2QQFUl@—AD2orthodonti—2servi™es2—re2—2limited2
˜enefitX2
@—A2yrthodonti™2servi™es2for2™osmeti™2re—sons2only2—re2not2—2™overed2
wedi™—id2servi™eF2yrthodonti™2servi™es2must2˜e2prior2—uthorized2—nd2
—re2 limited2to2 tre—tment2 of2severe2 h—ndi™—pping2 m—lo™™lusion2
—nd2
other2 rel—ted2 ™onditions2 —s2 des™ri˜ed2 —nd2 me—sured2
˜y2 the2
pro™edures2—nd2st—nd—rds2pu˜lished2in2the2„w€€wF2
por2most2of2the2 time2period2in2 questionD2 xovem˜er2lD2 PHHV2to2 eugust2
ID2 PHIID2
wedi™—id2oithodonti—2servi™es2 were2limited2 to2 ™hildren2twelve2ye—rs2of2—ge2—nd2
ixe™utive2gommissioner2—lso2de™lines2to2—dopt2the2ƒyG~’l~l2 evts2re™ommended2
pop2xoF2 lHD2 —s2st—ted2in2
their2t—nu—ry2ITD2PHIR2letter2to2the2ixe™utive2gommissionerF2
P2
e24legisl—tive2f—™t42 is2 —2mixed2question2of2f—™t2 —nd2l—w2—nd2defining2terms2 is2 —n2—gen™y2fun™tionF2 pF2
ƒ™ott2 w™gown2 82woni™—2veoD2 ‡hen2g—n2—n2Glgen™v2gh—nge2the2pindings2of@F4on™ltiFs9iHns2 of2—n2FRIDG€F‘2
€—rt2„woD2ƒl2 f—ylor2vF2 ‚evF2TQD2TWEUH2@IWWWAF2e2finding2of2f—™t2is2 —24legisl—tive2f—™t”2
where2the2 finding2
—ffe™ts2 not2just2 one2spe™ifi™2™—seF2 ˜ut2 is2 —™tu—lly2 —n2expli™—tion2
of2—gen™y2poli™y2 —nd2therefore2 m—y2˜e2
—pplied2to2other2™—ses2or2impli™—tes2—gen™y2poli™yF2sdF
T
001749
ƒee2
olderF2 ‚E2IS2—t2 IWEQV2§2 IWFIWFI2 @PHHW2„w€€wAF2es2writtenD2the2proposed2
finding2 does2 not2 —™™ur—tely2 refle™t2 wedi™—id2poli™yF2 ƒpe™ifi™—llyD2 the2 proposed2
finding2ol’2f—™t2omits2the2IP2ye—r2—ge2threshold2for2™hildren2eligi˜le2l’or2orthodonti—D2
erroneously2 suggesting2 ˜y2 impli™—tion2 th—t2 —ny2 ™hild2 under2 PH2 is2 eligi˜leF2
„hereforeD2 proposed2 finding2 of2 f—™t2 num˜er2 IH2 should2 ˜e2 modified2 to2 more2
—™™ur—tely2refle™t2the2limited2˜enefit2H9I’2 wedi™—id2orthodonti—2—s2 —rti™ul—ted2 in2 PS2
„exF2 edminF2 gode2 §2 QQFUl@—AY2 see2 „exF2 qov‘t2 gode2 PHHlFHSV@eA@IAD2
§2 @QA2
@—llowing2 —n2 —gen™y2 to2 ™h—nge2 —2 €ph2to2 ™orre™t2 errors2 of2 l—w2 or2 poli™y2 or2
te™hni™—l2errors2 in2—2proposed2finding2of2f—™tAF2 ƒee2—lsoD2 eFgFD2 ixF2‚EIUF2„2 w€€w2
@PHIIAD2 †olF2 PD2 §2 RFPFPRX2 ixF2 ‚EITD2„l’GI€€w2@PHIHAD2 †olF2 PD2 §2 SFQFPRY2 ixF2 ‚EISD2
„I’G{€€w2@PHHWAD2†olF2PD2§2 IWFIWY2ixF2‚EIRD2 „w€€w2
@PHHVAD2†olF2P2§2 IWFIWF2
e2™orre™t2underst—nding2of2the2limit—tions2of2„ex—s2wedi™—id’s2orthodonti—2˜enefit2
ex—mples2of2ehg2
is2espe™i—lly2import—nt2in2this2™—seD2‡here2there2—re2—2num˜er2of2
requesting2full2 ˜—nding2@˜r—™esA2for2™hildren2under2IP2ye—rs2of2—geFQ2 ƒeeD2 eF2gFD2 ixF2
‚EIS2 „I’Gl€€t’Gs2 @PHHWA2 §2 IWFlWFI2 @PHHW2 „w€€wA2@™omprehensive2 orthodonti™2
tre—tment2restri™ted2to2™lients2who2—re2 IP2ye—rs2of2—ge2or2older2or2™lients2who2h—ve2
exfoli—ted2—ll2 prim—ry2dentitionAF2 „he2ƒyer2evts2m—y2not2 in™orre™tly2revise2or2
in™orre™tly2interpret2the2me—ning2of2the2—gen™y’s2poli™iesF2 ƒee2ƒouthwest2€h—rmFD2
RHV2ƒF‡FQd2—t2 SSUESVY2‚F‚F2 gHmm’n2Hf„exF2 vF2 „exF2 glG9l€s’lƒD2 QQT2ƒF‡FQd2—t2 TPRF2
„he2 new2finding2 of2f—™t2 —™™ur—tely2 refle™ts2 the2 poli™y2 of2 „ex—s2 wedi™—id2 ot2
providing2—2very2limited2˜enefit2—nd2thus2—dv—n™es2the2 go—l2of2preserving2s™—r™e2
wedi™—id2doll—rs2 ˜y2—rti™ul—ting2the2limited2orthodonti™2˜enefitF2„exF2qov’t2gode2
§QlIFHPQ@lAF2
„he2ƒyer2evts2—lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlfngen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2polc2 PWD2QID2 —nd2QQD2 for2their2underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2 gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2of2„ex—s2 l—w2—nd2wedi™—id2
poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2 PHHlFHSV@eA@PAF2
§2
en2—™™ur—te2underst—nding2of2the2s™ope2—nd2limit—tions2of2„ex—s2wedi™—id2poli™y2
out™ome2of2this2 disputeF2„he2fund—ment—l2—lleg—tion2
is2 ™riti™—lly2 import—nt2to2 the2
˜rought2 ˜y2the2 snspe™tor2 qener—l2 is2 th—t2 ehg2h—s2 su˜mitted2 ™l—ims2 por2 prior2
—pprov—l2 @€eA2 —nd2 for2 reim˜ursement2th—t2 —re2 not2 —uthorized2 under2wedi™—id2
poli™y2or2„ex—s2l—wF2 elleg—tions2 ™—nnot2˜e2properly2ev—lu—ted2 if2the2 f—™t2 tinder2
does2 not2 properly2 interpret2 —nd2 —pply2 —2 poli™yF2 „herel˜reD2 there2 is2 —2 r—tion—l2
™onne™tion2 ˜etween2the2 ™orre™t2 —rti™ul—tion2 of2wedi™—id2poli™y2 —nd2 the2 —ltered2
finding2of2f—™tD2 whi™h2—™™ur—tely2refle™ts2th—t2poli™yF2ƒeeD2eFgFF2rerit—ge2on2the2ƒ—n2
q—˜riel2romeowners2esso™F2 vF2 „giD2QWQ2 ƒF‡FQd2RIUD2 RRHERI2 @„exF2 eppF~2
ii•2
eustin2PHIPD2pet2 deniedAY2ƒt—te2 vF2 widEƒouth2€—versD2 ln™FD2 PRT2ƒF‡FQd2UIID2 UPV2
’’h@2 request2full2˜—nding2@˜r—™esAF2hVHVHD2for2three2p—tientsF2€EISD2
€ESTD2—nd2€ETH2who2were2under2IP2ye—rs2of2—ge2
—t2time2oftre—tmentF
U
001750
@„exF2eppF~eustin2PHHUD2petF2deniedAY2vevy2vF2 „exF2 ƒt—te2fdF2HfwedF2ix—m2’rsD2 WTT2
ƒF‡FPd2VIQF2VIT2@„exF2eppF—eustin2IWWVD2no2petFAF2
II2 sn2PHHV2through2PHIID2„ex—s2wedi™—id2p—id2the2providers2of2orthodonti™2servi™es2
on2—2feeEforEservi™e2˜—sisF2
IP2 „o2˜e2reim˜ursed2for2orthodonti™2servi™esD2the2w—nu—l2required2dent—l2providers2to2
first2o˜t—in2prior2—uthoriz—tion2from2„wr€F2
IQ2 sn2m—king2prior2—uthoriz—tion2de™isions2in2orthodonti—2™—sesD2„wsEs€2relied2in2p—rt2
on2—2r—ndi™—pping2v—˜ioElingu—l2 hevi—tion2 @rvhA2s™ore2 sheet2 ™ont—ined2 in2 the2
w—nu—l2 to2 determine2 whether2 orthodonti™2 servi™es2 qu—lified2 por2 wedi™—id2
™over—geF2
IR2 „he2w—nu—l2required2providers2 to2 ™omplete2—nd2su˜mit2the2 l—llFh2 s™ore2sheet2to2
„w}E‘€2 together2 with2 —2 prior2 —uthoriz—tion2 request2 —nd2the2 supporting2 ™lini™—l2
m—teri—ls2 in™luding2 the2 tre—tment2 pl—nD2 ™eph—lometri™2 r—diogr—ph2 with2 tr—™ing2
modelsD2f—™i—l2photogr—phsD2r—diogr—phsD2the2model2@or2™—stA2of2the2 p—tient’s2teeth2
if2—2model2w—s2m—deD2 —nd2—ny2—ddition—l2 pertinent2 inform—tion2to2 ev—lu—te2 the2
requestF2
IS2 „he2rvh2lndex2is2 —n2index2me—suring2the2 existen™e2 or2—˜sen™e2of2h—ndi™—pping2
m—lo™™lusion2—nd2its2severityD2—nd2is2 —2tool2used2˜y2wedi™—id2to2me—sure2whether —2
p—tient2qu—lifies2for2the2pu˜li™2funding2progr—mF2lt2 is2 not2intended2to2˜e2di—gnosti™2
or2tre—tment2toolF2
IT2 „he2w—nu—l2des™ri˜ed2the2™—tegories2of2the2rvh2sndexD2—nd2instru™ted2providers2
on2how2to2s™ore2those2™—tegoriesF2
IU2 „he2 rvh2s™ore2 sheet2 —ssigned2 —2 ™ert—in2 num˜er2of2points2 for2 the2 pollowing2
o˜served2™onditionsX2 ™left2 p—l—teD2 severe2 tr—um—ti™2 devi—tionsD2 overjetD2 over˜iteD2
m—ndi˜ul—r2protrusionD2 open2˜iteD2 e™topi™2eruptionD2—nterior2™rowdingD2—nd2l—˜ioE2
lingu—l2spre—d2in2millimetersF2
IV2 yrthodonti™2servi™es2provided2solely2for2™osmeti™2re—sons2were2not2™overed2under2
the2„ex—s2wedi™—id2progr—mF2
IW2 elthough2„ex—s2wedi™—id2gener—lly2restri™ted2orthodonti™2tre—tment2to2™hildren2lP2
ye—rs2of2—ge2or2older2who2no2longer2h—d2prim—ry2teethD2 —2provider2™ould2request2
th—t2„wr€2—pprove2prior2—uthoriz—tion2for2inter™eptive2tre—tment2or2for2tre—tment2
for2—2™hild2who2qu—lified2for2—nother2ex™eption2under2the2progr—mF2
PH2 sn2gener—lF2orthodonti™2˜enefits2were2limited2to2the2tre—tment2of2™hildren2 IP2ye—rs2
of2—ge2or2older2with2—2severe2h—ndi™—pping2m—lo™™lusionF2sf2the2 rvh2 sndex2s™ore2
did2 not2 meet2 the2 PTEpoint2 thresholdF2 —2 provider2 ™ould2 su˜mit2 —2 n—rr—tive2 to2
est—˜lish2the2medi™—l2ne™essity2of2the2tre—tmentF2
PI2 xotwithst—nding2„l†sr€’s2 responsi˜ility2 for2 reviewing2the2 filed2 m—teri—l2 to2
ev—lu—te2 whether2the2 orthodonti™2 servi™es2 were2medi™—lly2 ne™ess—ry2˜efore
V
001751
gr—nting2 prior2 —uthoriz—tionD2 ehg2w—s2 required2 to2 su˜mit2—™™ur—te2 rvh2
s™oresheets2—nd2€e2requests2su˜st—nti—ting2the2p—tient’s2™ondition2—s2meeting2
wedi™—id’s2requirementsF2
@„he2 ƒyer2evts92 proposed2 pp2 xoF2 PI2 st—tedX2 „wr€2w—s2 responsi˜le2for2
reviewing2the2filed2m—teri—l2to2 ev—lu—te2 whether2the2 orthodonti™2 servi™es2 were2
medi™—lly2ne™ess—ijv2˜efore2gr—nting2prior2—uthoriz—tionFA2
‚e—son2for2gh—ngeX2
„he2proposed2finding2is2 not2simply2—2™—seEspe™ifi™2finding2of2f—™t2th—t2determines2
the2“whoF2wh—tD2‡henD2where2—nd2how”2of2this2™—seF2 ‚—therD2the2proposed2finding2
—ddresses2—2mixed2question2of2f—™t2—nd2l—w2—nd2is2 —2soE™—lled2“legisl—tive2findingF42
es2su™hD2 the2 ixe™utive2gommissioner2h—s2 “™omplete2dis™retion”2 to2 modify2the2
proposed2findingF2 „exF2 hep9t2of2vi™ensing282‚egul—tion2vF2 „hompsonD2 PHIQ2 ‡v2
QUWIRVTD2—t2 BT2 @“‘en2—gen™y2enjoys2™omplete2dis™retion2in2 modifying2—n2evt‘s2
findings2—nd2™on™lusions2when2those2 findings2—nd2™on™lusions2refle™t2 —2 l—™k2 ot2
underst—nding2or2mis—ppli™—tion2of2the2existing2l—wsD2rulesD2 or2poli™iesF4’2@quoting2
ƒmith2 vF2 wonlem—yorD2PHHQ2 ‡v2PIRHISWID2 —t2 BPTEPU2@emph—sis2 —ddedAAY2 „exF2
qov’t2gode2§2Py@AlFHSV@eA@IAF2
„he2ixe™utive2gommissioner2modifies2proposed2pop2xoF2PI2˜e™—use2the2proposed2
finding2 rests2 upon2 —n2 in™orre™t2 leg—l2 premiseF2 „he2 proposed2 finding2 of2 f—™t2
suggests2 th—t2 „wr€2is2 solely2 responsi˜le2 for2 the2 disposition2 of2—n2 orthodonti™2
prior2 —pprov—l2 @€eA2requestF2 „he2impli™—tion2 of2this2 proposed2finding2is2 th—t2 it2
there2were2—ny2errors2in2the2€es2—t2issue2in2this2™—seD24l9wles€‘2s2—pprov—ls2somehow2
m—de2the2ƒt—te2—t2 f—ult2for2ehg92s2 errorsF2 purtherD2 ehg2
—rgued2—t2 the2he—ringF2—nd2
the2 evts’2 proposed2 finding2 of2 f—™t2 seems2 to2 suggestD2 th—t2 on™e2 h—s2 „wr€2
—pproved2—2€e2requestF2ehg2™—nnot2˜e2held2li—˜le2for2its2ver—™ity2or2—™™ur—™yF2
€roposed2 finding2 of2 f—™t2 num˜er2 PI2 is2 erroneous2 ˜e™—use2 it2 misst—tesD2
misint™rpretsD2 —nd2mis—pplies2„ex—s2l—wF2 „he2˜l—™k2letter2 l—w2in2„ex—s2is2 ™ryst—l2
™le—rX2 the2equit—˜le2defenses2of2estoppel2—nd2l—™hes2do2not2run2—g—inst2the2ƒt—te2in2
the2 exer™ise2 of2its2 sovereign2powersF2 ƒee2ƒt—te2 vF2 hurh—rnD2 VTH2ƒF‡FPd2TQD2 TU2
@„exF2 IWWQAF‘2 ƒee2—lso2„exF2 qov4t2gode2§2 PHHIFHSV@eA@lA2 @“e2st—te2 —gen™y2m—y2
R2
„he2 ixe™utive2 gommissioner2notes2 th—t2 numerous2 „r—vis2gounty2histri™t2 gourts2 h—ve2 ruled2 on2the2
—ppli™—˜ility2ofequit—˜le2defensesF2su™h2—s2estoppelD2l—™hesD2w—iverD2r—tifi™—tion2—nd2limit—tionsF2in2—™tions2
˜rought2˜y2the2yffi™e2of2ettomey2qener—l2under2the2—uthority2of2the2 „wp€eF2 ln2e—™h2of2these2™—sesF2the2
distri™t2™ourts2h—ve2ruled2th—t2these2defenses2—re2not2—v—il—˜le2—s2—2m—tter2of2l—wF2 ƒeeD2eFgFD2ƒt—te2 „ex—s2
of2
ex2relF2 †enEeEg—re2ofthe2pl—F2 l’92e•vsD2 sn™F2 vF2‚ox—ne2v—˜sD2sn™F2 et2—lF2g—use2xoF2q†EHHPQPU2@•SQrd2tudi™i—l2
histF2gtF2„r—vis2gountyD2„exF2eugF2 ISD2 QHHQA2@yrder2gr—nting2€l—intit„s’2 pirst2emended2wotion2for2€—iti—l2
ƒumm—ry2tudgmentF2 whi™h2—ddressedF2 —mong2othersD2 defenses2 oi’2 limit—tionsD2 estoppelD2 l—™hesF2 w—iverF2
—nd2f—ilure2 to2 mitig—teAX2ƒt—te2of2„ex—s2exF2 relF2 †en~2F»lEg—re2 Gthe2pl—F2 ueysF2 sn™F2 vF2 ƒ—ndHXD2sn—D2g—use2
xoF2hElEq†~HUEHHIPSW2@P@Alst2tudi™i—l2 histF2 gtFF2 „r—vis2gountyD2„exF2 he™F2 IRF2 PHHWA2@tent—tive2 rulings2
m—de2from2˜en™h2gr—nting2ƒt—te9s2 p—rti—l2 motion2for2summ—ry2judgment2™on™erning2vi—˜ility2of2equit—˜le2
enses2—g—inst2the2st—te2@limit—tionsD2 estoppelF2l—™hesD2r—tifi™—tionAAX2 ƒl—te2of„eFr—s2ex2relF2 †er—EeEg—re2
d™t92
rgG‘the2pl—F2 ueysD2sn™F2 vF2elph—rm—2…ƒ€hF2g—use2xoF2hEs2Eq†EHVEHHISTT2@RlWth2tudi™i—l2histF2
gvD2„r—vis
W
001752
™h—nge2—2finding2of2f—™t2or2™on™lusion2of2l—w2 F2 F2 F2 ifF2 F2 the2evt“2did2not2properly2
F‘2
—pply2or2interpret2—ppli™—˜le2l—‡F”AF2
„he2proposed2finding2 —lso2 ignores2the2responsi˜ility2ehg2h—d2to2 su˜mit2truthful2
—nd2 —™™ur—te2 do™ument—tion2to2 the2 ƒt—te2 @in™luding2 the2 responsi˜ility2 expressly2
st—ted2 in2 the2 €rovider2 egreement2—nd2—greed2to2 ˜y2ehg2—ndGor2 its2
providersAD2
in™luding2—™™ur—te2rvh2s™oresheets2—nd2€e2requestsF2ƒee2—lso2ixF2‚ElRD2„w€€w2
@PHHVAD2 §2 IFPFU2 €rovider2 gertifi™—tionGessignment2 @“„ex—s2 wedi™—id2 servi™e2
providers2—re2required2to2™ertify2™ompli—n™e2with2or2—gree2to2v—rious2provisions2ot2
st—te2—nd2feder—l2 l—ws2—nd2regul—tionsF2efter2su˜mitting2—2signed2™l—im2to2
„wr€D2
the2provider2™ertifies2the2followingX2 „he2inform—tion2on2the2™l—im2form2is2 trueD2
F2 F2 F2
—™™ur—teD2—nd2™omplete”A2@emph—sis2—ddedAF2
ehg2produ™ed2no2eviden™e2or2leg—l2—uthority2to2show2 it2 w—s2somehow2—llowed2to2
provide2 fr—udulent2 or2 f—lse2 st—tementsD2 su˜mit2 ™l—ims2 for2 nonEreim˜urs—˜le2
servi™esD2or2eng—ge2in2—ny2™ondu™t2in2viol—tion2of2the2—ppli™—˜le2wedi™—id2progr—m2
rulesD2 ˜—sed2on2the2mere2f—™t2„2 wr€2—pproved2ehg’s2prior2—uthoriz—tion2™l—imsF2
ƒee2idF2 @ixF2‚EIRD2 „w€€w2 @PHHVAD2§2 IFPFU2€rovider2gertifi™—tionGessignmentAY2see2
—lso2re™kler2vF2 gommunity2IE‘e—ltlz2 ƒervszD2 RTU2…FƒF2SID2 TQETS2@IWVRA2 provider2
@—2
h—s2 the2 responsi˜ility2 to2 4f—mili—rize2 itself2with2 the2 leg—l2 requirements2 for2 ™ost2
reim˜ursement”AF2
„he2ƒyer2evts2—lso2erred2to2the2extent2th—t2they2relied2on2the2sEs—rlingeiz2p—mily2
heni—l2de™isionD2 p—rti™ul—rlyD2sQE‘op2 PWD2 QID2 —nd2QQD2 for2their2 underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2 gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2 l—w2—nd2 wedi™—id2
poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2 PHHIFHSV@eA@PAF2
§2
„hereforeD2the2ixe™utive2gommissioner2finds2th—t2the2€ph’s2proposed2finding2ot2
f—™t2 num˜er2PI2 eirs2 ˜e™—use2 it2 misst—tes2 „ex—s2l—w2 —nd2 suggests2
th—t2 is2 ehg2
ex™used2for2su˜mitting2f—lse2 inform—tion2if2 „wr€2
—pproved2ehg’s2€e2requestsF2
qiven2the2 issues2 in2 this2 p—yment2hold2 pro™eedingD2 there2 is2 therefore2 —2 r—tion—l2
™onne™tion2˜etween2„ex—s2l—w2—nd2the2—ltered2 finding2of2f—™tF2 ƒeeF2eF2gFF2 rerit—ge2
on2the2ƒ—n2q—˜riel2romeowners2esso™F2vF2 „giD2QWQ2ƒF‡FQd2—t2RRHERIY2ƒt—te2vF2
FwidEƒouth2 €—versD2 In™FD2 PRT2 ƒF‡FQd2 —t2 UPVY2 vevy2 vF2 „exF2 ƒl—te2 fdF2 G‘wedF2
ix—m rsD2WTT2ƒF‡FPd2—t2VITF2
92
PPF2 „he2w—nu—l2™l—rified2 th—t2 prior2 —uthoriz—tion2 of2—n2 orthodonti™2 servi™e2 did2 not2
gu—r—ntee2 p—ymentF2 „o2re™eive2 p—ymentD2the2 provider2 still2 h—d2to2 show2th—t2 the2
gountyD2„exF2 he™F2 lQD2 PHIHA2@order2striking2defense2of2f—ilure2 to2 mitig—teAY2ƒt—re2 „ex—s2ex2relF2
of2 ellen2
FGrmes2 vF2 FG—nsseiz2I’lI—rmFD2 sn™F2g—use2xoF2 hElEq†E@AREHHIPVV2@PStAth2
tudi™i—l2 histF2 gtFD2 „r—vis2gountyF2
„exF2pe˜F2PQF2PHI2lA2@order2striking2defenses2of2f—ilure2to2mitig—te2—nd2
limit—tionsAY2ƒt—le2f„v’ˆ@lƒ2exF2 relF2
qrmz—lez2vF2 wegoF2g—use2xoF2hElEq†Es2lEHHHURH2@PHlst2tudi™i—l2 histF2gtFD2„r—vis2
gountyF2„exF2ƒeptF2QHD2
PH2 QA2@two2ordersD2striking2defend—nts’2estoppelD2l—™h™sD2—nd2w—iver2defensesAF
s2
sH
001753
orthodonti™2pro™edure2w—s2medi™—lly2ne™ess—ry2under2the2terms2—nd2™onditions2of2
the2w—nu—lF2
PQ2 efter2ehg2provided2the2orthodonti™2tre—tment2to2 the2p—tients2in2this2™—seD2 „wr€2
—pproved2p—ymentF2
PR2 yn2eugust2PWD2 PHHVD2 rrƒgEysq2issued2 —2 perform—n™e2 —udit2 report2 reg—rding2
„Fwr€’s2prior2 —uthoriz—tion2pro™ess2 for2 the2 period2˜etween2ƒeptem˜er2 lD2 PHHTD2
—nd2 w—r™h2QID2 PHHVF2 finding2th—t2 „wr€’s2prior2 —uthoriz—tion2 pro™ess2 did2 not2
™omply2with2the2w—nu—l2@the2PHHV2—udit2reportAF2
PS2 sn2the2PHHV2—udit2reportD2 rrƒgEysq2found2th—t2„wr€’s2prior2—uthoriz—tion2st—ff2
f—iled2 to2 review2the2 supporting2m—teri—l2 su˜mitted2˜y2providers2with2their2prior2
—uthoriz—tion2requestsD2 —s2requiredF2—nd2th—t2„wr€’s2st—ff2did2not2h—ve2the2dent—l2
™redenti—ls2ne™ess—ry2to2ev—lu—te2whether2the2supporting2do™ument—tion2su˜mitted2
˜y2providers2supported2the2 rvh2 s™oreF2
PT2 „he2€rovider2 egreement2required2 ehg2—nd2its2 providers2 to2 ™ertify2 to2 ˜e2
truthfulY2 to2 —˜ide2˜y2the2wedi™—id2rulesY2 —nd2to2 su˜mit2trueD2™ompleteD2—nd2
—™™ur—te2 inform—tion2 th—t2 ™—n2 ˜e2 verified2 ˜y2 referen™e2 to2 sour™e2
do™ument—tion2m—int—ined2˜y2ehgF2
@„he2ƒyer2evts’2proposed2pop2xoF2PT2st—tedX2 ehg2w—s2un—w—re2of2the2 PHHV2
q s2—ssertion2tlz—t2 „wr€2w—s2not2properly2performing2
—u™lit2report2—nd2rrƒg~@As2
‘2
prior2—uthoriz—tion2ev—lu—tionsFA2
‚e—son2for2gh—ngeX2
„he2ixe™utive2gommissioner2modifies2the2 ƒyer2G’vFls’2 €roposed2pop2xoF2PT2
˜e™—use2the2proposed2finding2rests2 upon2—n2in™orre™t2 leg—l2 premiseF2es2su™hD2the2
ixe™utive2 gommissioner2 h—s2 “™omplete2 dis™retion”2 to2 modify2 the2 proposed2
findingF2 „exF2 hept‘2of2vi™ensing282‚egul—tion2vF2 „hompsonD2 PHIQ2‡v2QUWIRVTD2
—t2BT2@“en2—gen™y2enjoys2™omplete2dis™retion2in2modifying2—n2evt9s2findings2—nd2
™on™lusions2when2those2findings2—nd2™on™lusions2refle™t2—2l—™k2of2underst—nding2or2
mis—ppli™—tion2 of2 the2 existing2 l—wsD2 rulesD2 or2 poIi™iesF4’2 @quoting2 ƒmith2 vF2
wontem—yorD2PHHQ2 ‡v2 PIRHISWID2—t2 BPTEPU2@emph—sis2—ddedAAX2„exF2qov’t2gode2
§PHHIFHSV@eA@IAF2
„he2proposed2finding2suggests2th—t2ehg2™ould2not2h—ve2intention—lly2 su˜mitted2
f—lse2inform—tion2to2„wr€2 ˜e™—use2ehg2did2not2know2th—t2„wr€2w—s2f—iling2to2
properly2 review2 €e2requestsF2„his2is2 —2misst—tement2of2„ex—s2l—wF2es2—2threshold2
m—tterD2 the2 snspe™tor2 qener—l2 does2 not2 h—ve2 to2 show2 th—t2 ehg2m—de2 f—lse2
st—tements2 —nd2 m—teri—l2 misrepresent—tions2 with2 the2 spe™ifi™2 intent2 to2 defr—ud2
wedi™—idF2ƒee2„exF2 rumF2‚esF2 gode2ennF2 §2 QTFHHIl@˜A2@‡est2HIQA2@gulp—˜le2
went—l2 ƒt—teX2 spe™ifi™2 intent2 to2 defr—ud2 is2 not2 requiredAF2 snste—dD2 the2 inspe™tor2
qener—ls2 ˜urden2 in2 this2 p—yment2hold2 pro™eeding2 is2 to2 show2 ˜y2 prim—2 f—™ie2
eviden™e2 th—t2 when2ehg2su˜mitted2 f—lse2 inform—tion2 to2 „ex—s2 wedi™—id2 th—t
ll
001754
ehg2knew2the2 inform—tion2w—s2f—lseY2 @PA2 ehg2—™ted2with2 ™ons™ious2
either2 @IA2
indilleren™e2 to2 the2 truth2 or2 f—lsity‘2 ol’2 the2 inform—tionY2 or2 @QA2 ehg2—™ted2 with2
re™kless2disreg—rd2of2the2truth2or2f—lsity2of2the2inform—tionF2sdF2 @—A@lAE@QAF2
„he2ƒyer2esFls2—lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 pop2PWD2 QID2 —nd2QQD2 for2their2underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2 gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2l—w2—nd2wedi™—id2poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2§2PHHI2FHSV@eA@PAF2
woreoverD2given2the2—lleg—tions2—t2 issue2in2this2 p—yment2hold2pro™eedingD2—nd2the2
—™tu—l2st—nd—rd2under2the2„wp€eD2there2is2therefore2—2r—tion—l2™onne™tion2˜etween2
„ex—s2l—w2—nd2the2—ltered2finding2of2f—™tF2 ƒeeD2 eF2gFD2 rerit—ge2on2the2ƒ—n2q—˜riel2
romeowners2esso™F2 vF2 „2giD2QWQ2ƒF‡FQd2—t2RRHERIY2ƒt—te2vF2 llGlidEƒouth2€—versD2
sn™D2 PRT2ƒF‡FQd2—t2 UPVY2vevy2vF2 „exF2 ƒr—te2fdF2 ofwe™lF2ix—m2’rsD2 WTT2ƒF‡FPd2—t2
VITF2
PU2 ln2PHIID2rIEsƒgEysq2™ondu™ted2—2d—t—2—n—lysis2of2p—id2wedi™—id2™l—ims2in2„ex—s2
—nd2 determined2th—t2 ehg2w—s2one2 of2the2 top2 providers2 in2 the2 st—te2 with2high2
utiliz—tion2oforthodonti—2˜illing2˜etween2PHHV2—nd2PHIIF2es2—2resultD2rrƒgE@Al@“2
initi—ted2—2fr—ud2investig—tion2—g—inst2 ehgF2
PV2 rrƒgEysq2ret—ined2gh—rles2iv—nsD2hFhFƒFD2—n2orthodontistD2to2review2the2™lini™—l2
re™ords2for2the2TQEp—tient2s—mple2™olle™ted2˜y2lEllEsƒgEysq2for2whom2ehg2filed2
prior2—uthoriz—tion2requests2during2the2relev—nt2periodF2
PWF2 „he2 rvh2s™ore2 sheets2 for2 the2 TQ2 p—tients2 in2 the2 r—ndom2 s—mple2 were2
™ompleted2˜y2ehg9s2orthodontistD2‡—el2u—n——nD2hFhFƒF2—nd2hrF2x—z—riD2who2
is2 not2—n2orthodontistD2—nd2in2 e—™h2™—se2they2s™ored2the2p—tient2—s2
h—ving —2
s™ore2 of2PT2or2more2pointsF2 „he2gre—test2 num˜er2of2points2 w—s2—sso™i—ted2
with2the2™—tegory2of2“e™topi™2eruptionF42
@„he2ƒyer2evts’2proposed2 HIB2xoF2PW2st—tedX2 „he2rvh2s™ore2sheets2for2the2TQ2
IB‘2
p—tients2 were2 ™ompleted2˜y2ehgi2orthodontistD2 ‡—el2u—n——nD2 hFhFƒF2 —nd2hrF2
x—z—riD2 —nd2in2 e—™h2 ™—se2 the2 p—tient2 s™ored2PT2or2 more2pointsF2 „he2 gre—test2
num˜er2ofpoinls2w—s2—sso™i—ted2with2the2™—tegory2of24e™topi™2eruptionF2”A2
‚e—son2for2gh—ngeX2
„he2 ixe™utive2 gommissioner2 modifies2 the2 proposed2 finding2 ˜e™—use2 it2
mis™h—r—™terizes2 ˜y2omission2whi™h2p—rty2 h—s2responsi˜ility2for2 ™ompleting2the2
rvh2s™ore2 sheets2 —2the2 providerF2 es2su™hD2 the2 ixe™utive2 gommissioner2h—s2
4™omplete2dis™retion”2to2modify2the2proposed2findingF2 „exF2 hep9l42 vi™ensing 82
of2
‚egul—tion2vF2 „hompsonD2 PHIQ2‡v2QUWIRVTD2—t2BT2@“en2—gen™y2enjoys2™omplete2
dis™retion2 in2 modifying2—n2 eF‘Ft9s2 findings2—nd2™on™lusions2 when2those2 findings2
—nd2™on™lusions2refle™t2—2l—™k2of2underst—nding2or2mis—ppli™—tion2of2the2 existing
IP
001755
l—wsF2 rulesD2 or2poli™iesF”2@quoting2ƒmith2vF2 wontem—yorD2PHHQ2
BPTEPU2@emph—sis2—ddedAAY2„exF2qov’t2gode2 PHHI2
‡v2PIRHISWIF2—t2
§2 FHSV@eA@lAF2
rereD2hrsF2u—n——n2—nd2x—z—ri2s™ored2the2rvh2s™oresheetsD2—nd2represented2to2
the2
ƒt—te2the2—™™ur—™y2ofthe2s™oresF2 ‚EVQY2‚F‚F2†olF2Q2—t2RTEUHD2WTEWUY2
‚F‚F2†olF2R2—t2
WWEIHHF2 es2writtenD2 the2 proposed2 f—™t2 impermissi˜ly2 minimizes2the2
—™tive2 —nd2
responsi˜le2role2providers2h—ve2in2s™oring2p—tientsF2„ex—s2wedi™—id2depends2
upon2
the2providers2to2su˜mit2—™™ur—te2do™ument—tion2to2the2 ƒt—teY2
thusD2providers2˜e—r2
the2responsi˜ility2to2s™ore2the2p—tientsF2ƒee2„exF2qov’t2gode2
§2PHHlFHSV@eA@IAY2see2
—lso2ixF2‚EIRD2„l’Gs€€w2@PHHVAD2§2 IFPFU2€rovider2gertifi™—tionGessignment2
@“„ex—s2
wedi™—id2servi™e2 providers2 —re2 required2 to2 ™ertify2 ™ompli—n™e2with2or2 —gree2 to2
v—rious2provisions2of2st—te2 —nd2feder—l2 l—ws2 —nd2regul—tionsF2 efter2
su˜mitting —2
signed2™l—im2to2 „wr€D2the2provider2™ertifies2the2followingX2 F2 „he2inform—tion2
F2 F2
on2the2™l—im2form2is2 trueD2—™™ur—teD2—nd2™HmpleteF”A2@emph—sis2—ddedAF2
€roposed2pop2xoF2PW2is2 —lso2misle—ding2˜e™—use2it2 omits2the2f—™t2th—t2hrF2x—z—ri2
is2
not2—n2orthodontistF2„hereforeD2the2ixe™utive2gommissioner2is2
fully2—uthorized2 to2
™orre™t2 this2 te™hni™—l2 error2 @˜y2 omissionA2 in2 pop2xoF2 PWF2 „exF2 qov’t2
gode §2
PHHIFHSV@eA@QAF2
„he2ƒyer2evts2—lso2erred2to2the2extent2th—t2they2relied2on2the2l~9{—rlz92Gvgen2
p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 polc2 PWD2 QID2 —nd2QQD2 for2their2underst—nding2
of2the2
s™ope2—nd2 limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2
gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2
on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2l—w2—nd2
wedi™—id2poli™yD2 —nd2
thereforeF2™—nnot2˜e2relied2onF2 „exF2@}ov’t2gode2
§2PHHlFHSV@eA@PAF2
qiven2the2issues2 in2 this2 p—yment2hold2pro™eedingD2—nd2the2requirements2
of2„ex—s2
l—w2—nd2wedi™—id2poli™yD2 there2is2 therefore2—2r—tion—l2 ™onne™tion2˜etween2
„ex—s2
l—w2 —nd2 the2 —ltered2 finding2 of2f—™tF2 ƒeeD2 eF2gFD2 rerit—ge2 on2 the2 ƒ—n2
q—˜riel2
romeowners2esso™F2 vF2 „2 giD2QWQ2ƒF‡FQd2—t2 RRHERIY2ƒt—te2vF2 IIGlidEƒouth2€—versD2
ln™FD2 PRT2ƒF‡FQd2—t2 UPVY2v€l{}G2 vF2 „exF2 ƒt—te2f—’2
F2 of2wedF2ix—m2’rsD2 WTT2ƒF‡FPd2—t2
VITF2
hrF2 iv—ns2™on™luded2th—t2 in2 —ll2 TQ2™—sesF2 the2™lini™—l2 re™ords2did2
not2support2the2
s™oring2on2the2lEsvh2s™ore2sheets2su˜mitted2with2the2prior2—utlIori9GFF—tion2
requests2
˜e™—use2of2the2 s™ore2—ssigned2to2the2e™topi™2eruption2™—tegoryF2hrF2 iv—ns2
did2not2
testify2in2this2m—tterF2
elthough2rrƒgEqsq2represented2th—t2 its2 field2 investig—tors2 interviewed2ehg’s2
offi™e2st—ffF2 dentistsD2—nd2the2p—tients2—nd2their2p—rentsGgu—rdi—nsD2
it2 did2not2present2
this2eviden™e2during2the2he—ringF2
f—sed2in2 l—rge2 p—rt2 on2hrF2 iv—ns’2 ™on™lusionsD2 on2epril2 RF2 PHIPD2 rrƒgEy9Iq2
issued2—2letter2to2ehg2notifying2ehg2th—t2it2 w—s2imposing2—2 IHH72
p—yment2hold2
on2—ll2 future2 wedi™—id2reim˜ursements2due2to2 —2™redi˜le2 —lleg—tion2of2
fr—ud2for2
™l—ims2ehg2su˜mitted2from2xovem˜er2ID2 PHHV2through2eugust2
QID2PHI2IF
lQ
001756
QQ2 ehg2timely2requested2—2he—ring2to2™ontest2the2p—yment2holdD2—nd2the2m—tter2w—s2
relerred2to2the2 ƒt—te2yl’t92
I™e2 of2edministr—tive2re—rings2@ƒyerA2on2xovem˜er2
UD2
PHIPF2
QR2 rrƒgEylq2referred2ehg2to2the2wedi™—id2pr—ud2gontrol2…nit2ol’2the2yffi™e2of2the2
g…AD2 —nd2 on2 w—r™h2 PWD2 PHIPD2 wp2
ettorney2 qener—l2 @w€2 g…2 opened2 —n2
investig—tionF2
QS2 yn2t—nu—ry2ISD2 PHIQD2rrƒgEysq2issued2its2 pirst2emended2xoti™e2of2re—ring2to2
ehgF2„he2noti™e2 ™ont—ined2 —2 st—tement2 of2the2 timeD2 pl—™eD2 —nd2 n—ture2 of2the2
he—ringY2—2st—tement2of2the2leg—l2—uthority2—nd2jurisdi™tion2under2whi™h2the2
he—ring2
w—s2 to2 ˜e2heldY2 —2 referen™e2 to2 the2 p—rti™ul—r2 se™tions2 of2the2 st—tutes2 —nd2 rules2
involvedY2—nd2—2short2pl—in2st—tement2of2the2m—tters2—ssertedF2
QT2 „he2 he—ring2 on2 the2 merits2 w—s2 held2 w—y2 PV2 through2 QID2 PHIQD2 ˜efore2
edministr—tive2 v—w2tudges2g—therine2 gF2 ig—n2—nd2row—rd2ƒF2 ƒeitzm—n2 —t2 the2
ƒt—te2 yfti™e2 of2edministr—tive2 re—rings2 @ƒyerA2in2 the2 ‡illi—m2
€F2 glements2
fuildingD2 QHH2 ‡est2 ISth2 ƒtreetD2 pourth2 ploorD2 eustinD2 „ex—sF2 ehg2
—ppe—red2
through2its2 —ttorneys2 of2re™ordD2 FlFeF2 „ony2g—n—lesF2 re™tor2 g—n—lesD2 ‚o˜ert2wF2
endertonD2€hilip2 rF2 rilderD2 ‡illi—m2fF2 qr—h—mD2t—mes2qF2 ‚yttingD2 —nd2„hom—s2
‡—tkinsF2 rrƒgEysq2w—s2represented2˜y2outside2™ounsel2h—n2r—rgroveD2
g—itlyn2
ƒilh—nD2 t—mes2 ‚F2 wori—rtyD2 uet—n2 uh—rodY2 ˜y2 essist—nt2
ettorneys2 qener—l2
‚—ymond2gF2 ‡inter2—nd2w—rg—ret2wF2wooreD2from2the2yffi™e2of2ettorney2qener—l2
of„ex—sD2—nd2˜y2inrique2†—rel—2—nd2tohn2‚F2wedlo™kF2from2ssrƒgEysqF2
QU2 sn2the2PHHV2through2PHII2w—nu—ls2@w—nu—lsAF2the2 rvh2 index2des™ri˜ed2the2term2
4e™topi™2eruption”2—s2“—n2unusu—l2p—ttern2of2eruptionD2su™h2—s2
high2l—˜i—l2 ™uspids2
or2teeth2th—t2—re2grossly2out2of2the2long2—xis2of2the2—lveol—r2ridgeF”2
„he2w—nu—ls2
instru™ted2 providers2 not2 to2 in™lude2 @s™oreA2 teeth2 from2 —n2 —r™h2 if2
the2 provider2
™ounted2the2—r™h2in2the2™—tegory2for2—nterior2™rowdingF2por2e—™h2—r™hD2the2
w—nu—l2
further2 instru™ted2 th—t2 either2 the2 e™topi™2 eruption2 or2 —nterior2 ™rowding2
™ould2˜e2
s™oredD2˜ut2not2˜othF2
QV2 „he2w—nu—ls’2referen™es2to2high2l—˜i—l2 ™uspids2—nd2teeth2grossly2out2of2the2 long2
—xis2of2the2—lveol—r2ridge2were2nonex™lusive2ex—mples2of2e™topi™2
eruptionF2
QW2 „he2w—nu—l2requires2 providers2 to2 —pply2the2 rvh2s™oring2 methodology2in2
—™™ord—n™e2with2their2profession—l2tr—iningD2edu™—tion2—nd2gener—lly2—™™epted2
st—nd—rds2in2the2dent—l2professionF2emong2those2st—nd—rds2is2 the2st—nd—rd2for2
identifying2e™topi™2eruptionF2
@„he2 evts42 proposed2 pop2 xoF2 QW2 st—tedX2 „he2 w—nu—l s2 definition2
of2e™topi™2
92
eruption2 in2 the2 PHHV2 through2 PHGI2 itG‘—ntG—l2 required2 su˜je™tive2
judgment2 to2
interpretFA2
‚e—son2for2gh—ngeX
sR
001757
„he2 proposed2 finding2 —ddresses2 —2 mixed2 question2 of2 f—™t2 —nd2 l—wD2 —nd2 is —2
“legisl—tive2 findingF”2 es2 su™hD2 the2 ixe™utive2 gommissioner2
h—s2 “™omplete2
vi™ensing282‚egul—tion2vF2 „hompsonD2 PHIQ2
dis™retion42to2modify2itF2 „exF2hep’t2of2
‡sF2 QUWFIRVTD2 —t2 BT2 @“‘en2 —gen™y2enjoys2 ™omplete2 s™retz92on2 in2 modifying2—n2
—9I92
evt9s2findings2—nd2™on™lusions2when2those2findings2—nd2™on™lusions2
refle™t2—2l—™k2
of2 underst—nding2 or2 mis—ppli™—tion2 of2 the2 existing2 l—wsD2 rulesD2 or2 poli™iesF”2
@quoting2ƒmith2vF2wontemtnGorD2PHHQ2 ‡v2
PIRHISWID2—t2BPTEPU2@emph—sis2—ddedAAY2
„exF2qov’t2gode2§2PHHIFHSV@eA@IAF2
„he2 ixe™utive2 gommissioner2 modifies2 €roposed2 pop2 xoF2 QW2 ˜e™—use2 it2 is2
erroneous2for2two2re—sonsF2pirstD2the2„2 w€€w9s2dis™ussion2of2e™topi™2eruption2is2—n2
instru™tionD2 not2 —2 definitionF2 ƒeeD2 eFgFD2 ‚F‚FD2 †olF2 I2 —t2 IHQXVEIP2
@terms2 in2 the2
e™topi™2 eruption2 instru™tion2 —re2 not2 defined2 ˜ut2 —re2 —™™orded2 their2
pl—in2 —nd2
ordin—ry2me—ning2in2 the2inglish2l—ngu—geAY2‚F‚FD2†olF2 I2 —t2 IIIX2 IPEIR2@providers2
must2underst—nd2the2 m—nu—l2˜y2virtue2 of2their2profession—l2 tr—iningAF2 „his2error2
refie™ts2—2misinterpret—tion2of2l—w2—nd2poli™y2˜y2the2ƒyer2evt2 sF2 ƒee2„exF2@}ov’t2
gode2§2 PHHIFHSV@eA@IAY2„hompsonD2PHIQ2 ‡v2
QUWIRVTD2—t2 BTY2ƒouthwest2€h—rmFD2
RHV2ƒF‡FQd2—t2SSUESVF2
ƒe™ondD2 the2 proposed2 finding2erroneously2 suggests2 th—t2 it2 w—s2„ex—s2 wedi™—id2
poli™y2 to2 —dopt2 —2 distin™t2 “definition”2 of2e™topi™2 eruption2 in2 the2 „w€€w2
th—t2
differed2 from2 e™topi™2 eruption2 —s2 gener—lly2 understood2 within2
the2 dent—l2
professionF2 „he2proposed2 finding2would2viol—te2 st—te2 —nd2 feder—l2 l—w2
˜e™—use2
™re—tion2of2—2different2set2of2st—nd—rds2—ppli™—˜le2only2to2wedi™—id2
p—tients2would2
viol—te2˜oth2„ex—s2—nd2feder—l2l—wF2ƒeeD2 eF2gFD2 I2 „exF2edminF2gode2
§2 QSRFlIQI@hAY2
see2—Gso2‚‚FD2†olF2QD2 PSHXVEIWY2ixF2‚EIR2@PHHV2„w€€wAD2 IFPFSY2 ixF2‚EIS2
§2 @PHHW2
„I’Gll’€wAF2 §2 IFRFS2 @“gompli—n™e2 with2 peder—l2 vegisl—tionF2 ‚eminderX2 i—™h2
provider2mztstfurhish2™overed2wedi™—id2servi™es2in2the2s—me2m—nnerD2to2the2s—me2
extentD2 —nd2of2the2 s—me2qu—lity2—s2servi™es2provided2to2 other2
p—tientsF2 ƒervi™es2
m—de2—v—il—˜le2to2other2p—tients2must2˜e2m—de2—v—il—˜le2to2„ex—s2wedi™—id2™lients2
if2the2 servi™es2 —re2 ˜enefits2 of2the2 „ex—s2Fwedi™—id2€rogr—GIPF”AF2 end2in2
f—™tD2 —ll2
pu˜lished2poli™y2do™uments2promulg—ted2˜y2rrƒg2require2providers2to2
—pply2the2
s—me2st—nd—rds2 of2™—re2 to2 wedi™—id2p—tients2 they2 —pply2with2 the2 popul—tion2 —t2
l—rgeF2ƒeeF2 eFgFD2 ixF2‚EITD2—t§2IFTY2 ixF2‚EISD2 IWFPF2
§2
„hirdD2 the2 ƒyess2evts‘2 proposed2 finding2 suggests2 th—t2 the2
determin—tion2 of2
whether2—2 p—tient2 exhi˜ited2 e™topi™2 eruption2 w—s2 left2 entirely2 to2 the2 su˜je™tive2
opinion2of2the2tre—ting2dentistF2 „his2is2 wrong2˜e™—use2wedi™—id2
poli™y2do™uments2
—nd2the2testimony2of2—gen™y2witnesses2shows2th—t2dentists2were2instru™ted2to2
use2
their2 edu™—tionD2 tr—iningD2 —nd2experien™e2 in2 ev—lu—ting2
p—tientsF2 ƒeeD2 eFgFF2 ‚F‚FD2
†olF2 I2 —t2 IHQXVEIP2@terms2in2 the2e™topi™2eruption2instru™tion2
—re2not2defined2˜ut2—re2
—™™orded2their2pl—in2—nd2ordin—ry2me—ning2in2 the2 inglish2l—ngu—geAY2
‚F‚FD2†olF I2
—t2 IIIX2 IPEIR2 @providers2 must2 underst—nd2 the2
m—nu—l2 virtue2 of2
˜y2 their2
profession—l2tr—iningAF
IS
001758
provin™e2of2rrƒg2to2determine2wh—t2wedi™—id2poli™y2isD2 —nd2is2 notY2 the2
st2 is2 the2
ƒyer2evFls2h—ve2no2—uthority2to2wrongly2determine2wedi™—id2poli™yF2ƒouthwest2
€h—rmFD2 RHV2 ƒF‡FQd2 —t2 SSUESV2 @4‘‡“e2 must2 uphold2 —n2 enfor™ing2 —gen™y9s2
™onstru™tion2if2it2 is2 re—son—˜le2—nd2in2h—rmony2with2the2st—tute2 „his2deferen™e2
F2 F2 F2
is2 p—rti™ul—rly2 import—nt2 in2 ™onstruing2 —2 ™omplex2 st—tutory2 s™heme2 like2
wedi™—id”A2@™iting2 ‚F‚F2 gomm2’n2 of2„exF2 vF2 „exF2 gitizensD2 QQT2 ƒF‡FQd2—t2 TPR2
@™ourt2will2defer2to2—gen™y9s2™onstru™tion2of2st—tute2th—t2is2™ommitted2to2—gen™y2for2
enfor™ementF2 —s2 long2 —s2 the2 interpret—tion2 is2 re—son—˜le2 —nd2not2 ™ontr—ry2to2 the2
st—tute’s2 pl—in2 l—ngu—geAY2 see2 —lso2 et—s™os—2 gntyF2 vF2 et—s™os—2 gntyF2 eppr—is—l2
histD2 WWH2ƒF‡F2Pd2PSSD2PSV2@„exF2 IWWWA2@™ourts2m—y2not2—™™ept2interpret—tions2of2
—2st—tute2 th—t2 defe—t2the2purpose2of2the2 legisl—tion2 so2 long2 —s2 —nother2re—son—˜le2
interpret—tion2existsAY2„exF2qov‘t2gode2§2 Q2l2 l2 HPQ@TAF2
„he2ƒyer2evts2—lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2p—rti™ul—rlyF2 pop2PWD2 QID2 —nd2QQD2 for2their2underst—nding2of2the2
s™ope2—nd2 limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2 gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2l—w2—nd2wedi™—id2poli™yF2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2@}ov’t2gode2§2PHHI2FHSV@eA@PAF2
en2—™™ur—te2underst—nding2of2the2s™ope2—nd2limit—tions2of2„ex—s2wedi™—id2poli™y2
out™ome2of2this2 disputeF2 „he2fund—ment—l2—lleg—tion2
is2 ™riti™—lly2 import—nt2to2the2
˜rought2˜y2the2snspe™tor2qener—l2is2th—t2ehg2h—s2su˜mitted2™l—ims2for2€e2—nd2for2
reim˜ursement2 th—t2 —re2 not2 —uthorized2 under2 wedi™—id2 poli™y2 or2 „ex—s2 l—wF2
elleg—tions2 ™—nnot2 ˜e2 properly2 ev—lu—ted2 if2 the2 f—™t2 finder2 does2 not2 properly2
interpret2—nd2—pply2—2poli™yF2„hereforeD2there2is2 —2r—tion—l2™onne™tion2˜etween2the2
™orre™t2 —rti™ul—tion2 of2wedi™—id2 poli™y2 —nd2 the2 —ltered2 finding2 of2f—™tD2 whi™h2
—™™ur—tely2refle™ts2th—t2poli™yF2ƒeeF2eFgFD2rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2
esso™F2 vF2 „giD2QWQ2 ƒF‡FQd2—t2 RRHERIY2 ƒt—te2 vF2 wi—’Eƒouth2 €—versD2 In™FD2 PRT2
ƒF‡FQd2—t2UPVY2vevy2vF2 „exF2ƒt—te2fdF2oftlGfedF2ix—m rsD2 WTT2ƒF‡FPd2—t2VITF2
‘2
„he2w—nu—l’s2instru™tion2reg—rding2e™topi™2eruption2w—s2—mendedD2effe™tive2
t—nu—ry2ID2 PHIP2@PHIP2w—nu—lAD2to2 in™lude2the2following2senten™eX2 i™topi™2
eruption2does2not2in™lude2teeth2th—t2—re2rot—ted2or2teeth2th—t2 —re2le—ning2or2
sl—nted2espe™i—lly2when2the2en—melEgingiv—l2jun™tion2is2 within2the2long2—xis2of2
the2—lveol—r2ridgeF2 „his2—mendment2™l—rified2existing2„ex—s2wedi™—id2poli™y2
reg—rding2™onditions2qu—lifying2—s2e™topi™2eruption2—nd2did2not2su˜st—ntively2
™h—nge2„ex—s2wedi™—id2poli™yF2
@„he2 ƒyer2e‘Fts’2 proposed2 pop2xoF2 RH2 st—tedX2 „he2 w—nu—l2’s2 definition2 of2
e™topi™2 eruption2 w—s2 —mendedD2 effe™tive2 t—nu—ry2 ID2 PHIP2 @PHIP2 w—nu—lAF2 to2
in™lude2the2folGowing2senten™eX2 i™topi™2eruption2does2not2in™lude2teeth2 th—t2—re2
rot—ted2or2teeth2 th—t2—re2le—ning2or2sl—nted2espe™i—lly2when2the2 etz™mielEgingiv—l2
jun™tion2is2within2the2long2—xis2of2
the2—lveol—r2ridgeFA2
‚e—son2for2gh—ngeX2
lT
001759
pinding2of‘2 p—™t2xoF2RH2™on™erns2—n2 interpret—tion2of2rrƒg4s2intent2 in2 —dopting2
™h—nges2 to2 wedi™—id2 poli™yF2 es2su™hD2 the2 proposed2 finding2—ddresses2 —2 mixed2
question2 of2 l—w2 —nd2 f—™t2 —nd2 is2 —2 “legisl—tive2 findingF”2 „he2 ixe™utive2
gommissioner2h—s2™omplete2dis™retion2to2modify2the2proposed2findingF2 „exF2hep9t2
82
of2vi™ensing2 ‚egul—tion2vF2 „hompsonD2 PHIQ2 ‡v2
QUWIRVTD2—t2 BT2@“‘en2—gen™y2
enjoys2™omplete2dis™retion2in2modifying2—n2evt’s2findings2—nd2™on™lusions2when2
those2findings2—nd2™on™lusions2refle™t2—2l—™k2of2underst—nding2or2mis—ppli™—tion2oi2
the2existing2 l—wsD2rulesD2 or2poli™iesc”2 @quoting2ƒmith2vF2 wontem—yorD2
PHHQ2 ‡v2
PIRHISWID2—t2’E‘PTEPU2@emph—sis2—ddedAAY2„exF2qov’t2gode2 PHHI2FHSV@eA@lFAF2
§2
„he2 ixe™utive2 gommissioner2 modifies2 the2 proposed2 finding2 ˜e™—use2 the2
@iA2
„w€€w’s2dis™ussion2of2e™topi™2eruption2is2 —2s™oring2instru™tionF2not2—2definitionY2
—nd2@iiA2 the2 proposed2pop2misle—dingly2 suggests2th—t2 the2 PHIP2—mendment2w—s2
su˜st—ntive2 —nd2not2™l—rifyingF2 „hese2errors2refle™t2—2misinterpret—tion2of2l—w2
—nd2
wedi™—id2poli™y2˜y2the2ƒyer2evtsF2ƒee2„exF2qov9t2gode2 PHHlFHSV@eA@lAY2„exF2
§2
hep9t2 of2vi™ensing2 82‚egul—tion2 vF2 „hompsonD2 PHIQ2 ‡v2
QUWIRVTD2 —t2 BTY2
ƒourGnvest2€h—rmFD2 RHV2ƒF‡FQd2—t2 SSUESVF2 pirstD2 the2 „w€€w2provides2—2s™oring2
instru™tionD2 not2definitionF2ƒeeF2 eFgFD2‚F‚FD2†olF2 I2 —t2 IHQXVEIP2@terms2in2the2
e™topi™2
eruption2 instru™tion2 —re2 not2 defined2 ˜ut2 —re2 —™™orded2 their2 pl—in2 —nd2
ordin—ry2
me—ning2in2 the2 inglish2l—ngu—geAX2 ‚F‚FD2 †olF2 I2 —t2 lllX2 IPEIR2 @providers2 must2
underst—nd2the2m—nu—l2˜y2viitu™2oftheir2profession—l2tr—iningAF2
ƒe™ondD2—s2proposed2˜y2the2ƒyer2evtsD2pHII‘2xoF2RH2erroneously2suggests2th—t2the2
t—nu—ry2PHIP2—mendment2to2 the2 l—ngu—ge2in2 the2w—nu—l2signified2—2su˜st—ntiveD2
r—ther2 th—n2 ™l—rifyingD2 ™h—ngeF2 „he2PHIP2 —mendment2to2 the2 instru™tions2
in2 the2
„w€€w2™l—rified2 existing2 wedi™—id2 poli™yY2 the2 —mendment2 did2 not2 effe™t —2
su˜st—ntive2 ™h—ngeF2 ƒee2‚F‚FD2 †olD2 I2 —t2 WQXPEWD2 WRXPHEPQ2 @hrF2 eltenhoffAD2
‚F‚FD2
†olF2 Q2 —t2 IWQXlVEIWRXIY2 PWRIPIEPQ2 @t—™k2 ƒti™kAF2 lt2 is2 the2 provin™e2 of2sEEsrƒg2
to2
determine2wh—t2wedi™—id2poli™y2isD2 —nd2is2 notY2the2ƒyer2evFls2h—ve2no2
—uthority2
to2wrongly2determine2wedi™—id2poli™yF2ƒouthwest2€lz—rmFD2 RHV2
ƒF‡FQd2—t2 SSUESV2
@4‘‡“™2must2uphold2—n2enfor™ing2—gen™y9s2™onstru™tion2if2it2 is2 re—son—˜le2—nd2in2
h—rmony2with2the2st—tute2 „his2deferen™e2is2p—rti™ul—rly2import—nt2in2™onstruing2
F2 F2 F2
—2™omplex2st—tutory2s™heme2like2 wedi™—id”A2@™iting2‚F‚F2 gomm2‘n2 of2„exF2 vF2 „exF2
gitizensD2 QQT2 ƒF‡FQd2 —t2 TPR2 @™ourt2 will2 defer2 to2 —gen™y9s2 longEst—nding2
™onstru™tion2of2st—tute2th—t2is2 ™ommitted2to2—gen™y2for2enfor™ementD2—s2long2—s2
the2
interpret—tion2is2 re—son—˜le2—nd2not2™ontr—ry2to2 the2 st—tute9s2 pl—in2
l—ngu—geAY2see2
—lso2et—s™os—2gntyF2vF2er—s™os—2gntjvF2 eppr—is—l2FhisrFD2 WWH2ƒF‡F2Pd2
PSSD2PSV2@„exF2
IWWWA2@™ourts2m—y2not2—™™ept2interpret—tions2of—2st—tute2th—t2defe—t2the2purpose2
ot2
the2 legisl—tion2 so2 long2 —s2 —nother2 re—son—˜le2 interpret—tion2
existsAY2 „exF2 qov9t2
gode2§2QI2IFHPQ@TAF2
„he2ƒyesEs2eFvts2—lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 pop2PWD2 QID2 —nd2QQF2 for2their2 underst—nding2of2
the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2 gommissioner
lU
001760
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2l—w2—nd2wedi™—id2poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2§2PHHI2FHSV@eA@PAF2
en2—™™ur—te2underst—nding2of2the2s™ope2—nd2limit—tions2of2„ex—s2wedi™—id2poli™y2
is2 ™riti™—lly2 import—nt2to2the2out™ome2of2this2 disputeF2„he2fund—ment—l2—lleg—tion2
˜rought2˜y2the2snspe™tor2qener—l2is2 th—t2ehg2h—s2su˜mitted2™l—ims2for2€e2—nd2for2
reim˜ursement2th—t2—re2not2—uthorized2under2wedi™—id2poli™y2or2„ex—s2l—wF2„hese2
—lleg—tions2™—nnot2˜e2properly2ev—lu—ted2if2the2 finder2of2f—™t2does2not2underst—nd2
the2 poli™yF2 „hereforeD2 there2 is2 —2 r—tion—l2 ™onne™tion2 ˜etween2 the2 ™orre™t2
—rti™ul—tion2 of2wedi™—id2poli™y2—nd2the2 —ltered2 finding2of2f—™tD2 whi™h2—™™ur—tely2
refle™ts2th—t2poli™yF2ƒeeD2eF2gFD2 rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2esso™F2 vF2
„giD2QWQ2ƒF‡FQd2—t2RRHERIY2ƒt—te2vF2 widEƒouth2€—versD2sn™FD2 PRT2ƒF‡FQd2—t2UPVY2
vevy2vF2 „exF2ƒt—te2felF2 of2wedF2ix—m2’rsD2 WTT2ƒF‡FPd2—t2VITF2
„he2 l—ngu—ge2 in2 the2 w—nu—ls2 provided2 instru™tions2 to2 dentists2 —nd2
orthodontists2 to2 s™ore2 e™topi™2 eruption2 ™onsistently2 with2 the2 st—nd—rds2 for2
e™topi™2eruption2th—t2—re2gener—lly2re™ognized2in2the2dent—l2professionF2
@„he2 ƒyG’l~‘s2 evts’2 proposed2pop2xoF2 RI2 st—tedX2 „he2 l—ngu—ge2in2 the2 w—nu—ls2
provided2™t2 ™t9e•9finitiHtz2 fe™topi™2eruption2solely2for2use2in2s™oring2the2rvh2index2to2
tju—liGjI•Gor2p—ymentFA2
‚e—son2for2gh—ngeX2
pinding2of2p—™t2xoF2RI2 finding2—ddresses2—2mixed2question2of2l—w2—nd2f—™t2—nd2is —2
“legisl—tive2 findingF42 „he2 ixe™utive2 gommissioner2h—s2 ™omplete2 dis™retion2 to2
82
modify2the2proposed2findingF2 „exF2 hep9t2Hfvi™ensing2 ‚egul—tion2vF2 „hompsonD2
PHIQ2 ‡v2 QUWIRVTD2—t2 BT2@“‘en2—gen™y2enjoys2™omplete2dis™retion2in2modifying2
—n2G’vFl9s2 findings2—nd2™on™lusions2when2those2findings2—nd2™on™lusions2retle™t —2
l—™k2of2underst—nding2or2mis—ppli™—tion2of2the2existing2l—wsD2rulesD2 or2poli™iesG”2
@quoting2ƒmith2vF2wontem—yorD2PHHQ2 ‡v2
PIRHISWID2—t2BPTEPU2@emph—sis2—ddedlAY2
„exF2qov‘t2gode2§2PHHlFFHSV@eA@IAF2
„he2ixe™utive2 gommissioner2modifies2€roposed2pp2xoF2 RI2 for2 two2 re—sonsF2
pirstD2 the2 „w€€w’s2 dis™ussion2 of2 e™topi™2 eruption2 is2 —n2 instru™tionD2 not —2
definitionF2 ƒeeD2 eFgFD2 ‚F‚FD2 †olF2 I2 —t2 lHQXVElP2 @terms2 in2 the2 e™topi™2 eruption2
instru™tion2—re2 not2defined2˜ut2—re2—™™orded2their2pl—in2 —nd2ordin—ry2me—ning2in2
the2inglish2l—ngu—geAY2F‚FF‚FD2 †olF2 l2 —t2 llli2 lPElR2@providers2must2underst—nd2the2
m—nu—l2 ˜y2 virtue2 of2 their2 profession—l2 tr—iningAF2 „his2 error2 refle™ts —2
misinterpret—tion2of2l—w2—nd2poli™y2˜y2the2 ƒyer2evtsF2ƒee2„exF2 qov’t2gode §2
PHHlFHSV@™A@lAY2 „hompsonD2 PHIQ2 ‡v2 QUWIRVTF2 —t2 BTY2 ƒouthwest2 €h—rntD2 RHV2
ƒF‡FQd2—t2SSUESVF2
ƒe™ondD2 the2 proposed2finding2erroneously2 suggests2 th—t2 it2 w—s2„ex—s2 wedi™—id2
poli™y2 to2 —dopt2 —2 distin™t2 “definition”2 of2e™topi™2 eruption2 in2 the2 „w€€w2th—t2
ditiered2 from2 e™topi™2 eruption2 —s2 gener—lly2 understood2 within2 the2 dent—l
lV
001761
professionF2„he2 ƒyer2elFts’2proposed2finding2would2viol—te2st—te2—nd2feder—l2l—w2
˜e™—use2 ™re—tion2 of2 —2 different2 set2 HI92 st—nd—rds2 —ppli™—˜le2 only2 to2 wedi™—id2
p—tients2would2viol—te2˜oth2„ex—s2—nd2peder—l2l—wF2ƒeeD2 eF2gFD2 I2 „exF2edminF2gode §2
QSRFIIQI@hAY2see2 —lso2 ‚‚D2†olF2 QD2 PSHXVEIWY2ixF2 ‚EIR2@PHHV2„w€€wAD2§2 IFPFSY2
ixF2 ‚EIS2 @PHHW2 „w€€wAD2 §2 IFRFS2 @“gompli—n™e2 with2 peder—l2 vegisl—tionF2
‚eminderX2 i—™h2provider2 must2furnish2 ™overed2llG‘e™li™—i™l2 servi™es2 in2 the2 s—me2
m—nnerD2to2the2s—me2extentD2 —nd2of2the2s—me2qu—lity2—s2servi™es2prHvi—9e—92to2other2
p—tientsF2 ƒervi™es2 m—de2—v—il—˜le2 to2 other2p—tients2 must2˜e2 m—de2—v—il—˜le2 to2
„ex—s2 we™li™—i™l2 ™lients2 if2 the2 servi™es2 —re2 ˜enefits2 of2the2 „ex—s2 wedi™—id2
€rogr—m4AF2end2in2 f—™tD2 —ll2 pu˜lished2poli™y2do™uments2promulg—ted2˜y2rrƒg2
require2providers2to2 —pply2the2 s—me2st—nd—rds2of2™—re2to2 wedi™—id2p—tients2 they2
—pply2with2the2popul—tion2—t2l—rgeF2ƒeeD2 eFgFD2 ixF2‚EITD2—t2§2 IFTY2ixF2‚EISD2§2 IWFPF2
‚—ther2th—n2 impermissi˜ly2employing2 —2 spe™i—l2 or2unique2definition2 of2e™topi™2
eruption2 solely2 for2 use2 in2 the2 wedi™—id2™ontextD2 rrƒg2 poli™y2 m—kers2 inste—d2
instru™ted2providers2 to2 use2their2 tr—iningD2 edu™—tionD2 experien™eD2 —nd2definitions2
gener—lly2 understood2 in2 the2 pr—™ti™e2 of2 dentistry2 in2 qu—lifying2 —nd2 tre—ting2
wedi™—id2p—tients2—nd2to2senGe2these2p—tients2in2the2s—me2m—nner2—s2other2p—tientsF2
ƒeeF2 eFgFD2 ‚F‚FF2†olF2 I2 —t2 IHQXVEIP2@terms2in2the2e™topi™2eruption2instru™tion2—re2not2
defined2 ˜ut2 —re2 —™™orded2 their2 pl—in2 —nd2 ordin—ry2 me—ning2 in2 the2 inglish2
l—ngu—geAY2‚F‚FD2 †olF2 l2 —t2 lllX2 IPEIR2@providers2 must2underst—nd2the2 m—nu—l2˜y2
virtue2of2their2profession—l2tr—iningAF2
„he2ƒyer2evt2
s2 —lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyF2l~‘op2 PWD2 QID2 —nd2QQD2for2their2 underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2 l—w2—nd2wedi™—id2poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2§2PHHIFHS2V@eA@PAF2
en2—™™ur—te2underst—nding2of2the2s™ope2—nd2limit—tions2of2„ex—s2wedi™—id2poli™y2
out™ome2of2this2 disputeF2„he2fund—ment—l2—lleg—tion2
is2 ™riti™—lly2 import—nt2to2 the2
˜rought2˜y2the2snspe™tor2qener—l2is2 th—t2ehg2h—s2su˜mitted2™l—ims2for2€e2—nd2for2
reim˜ursement2th—t2—re2not2—uthorized2under2wedi™—id2poli™y2or2„ex—s2l—wF2„hese2
—lleg—tions2™—nnot2˜e2properly2ev—lu—ted2it“2 the2 finder2of2f—™t2 does2not2underst—nd2
the2 poli™yF2 „hereforeD2 there2 is2 —2 r—tion—l2 ™onne™tion2 ˜etween2 the2 ™orre™t2
—rti™ul—tion2 of2wedi™—id2poli™y2—nd2the2 —ltered2 finding2of2f—™tD2 whi™h2—™™ur—tely2
refle™ts2th—t2poli™yF2ƒeeD2eF2gFF2 rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2esso™F2 vF2
„giF2QWQ2ƒF‡FQd2—t2RRHERIY2ƒt—te2vF2 wid~ƒHzGth2€—versD2‘n™FD2 PRT2ƒF‡FQd2—t2UPVY2
vevy2vF2 „exF2ƒt—te2fdF2 ofllGse™lF2 ix—m rsD2 WTT2ƒF‡FPd2—t2VITF2
’2
„he2w—nu—l2did2 not2 —ddress2 how2—n2 orthodontist2 di—gnosed2 or2 tre—ted —2
p—tientD2˜ut2only2instru™ted2providers2to2s™ore2—nterior2teeth2™onsistently2with2
the2 gener—lly2 understood2 definition2 of2 e™topi™2 eruption2 in2 the2 orthodonti™2
professionF
sW
001762
s’2 proposed2pop2xoF2RP2st—tedX2 „he2w—nu—ls2did2not2—ddress2how2
@„he2ƒyGE’r2evt2
—n2orthodontist2di—gnosed2or2tre—ted2—2p—tientD2 ˜ut2only2defined2e™topi™2eruption2
for2 s™oring2 the2 rvh2s™ore2 sheet2 to2 determine2 —2 „ex—s2 wedi™—id2p—tient2
’s2
eligi˜ilityfor2orthodonti™2tre—tmentFA2
‚e—son2for2gh—ngeX2
€roposed2pyp2xoF2RP2—ddresses2—2mixed2question2of2f—™t2—nd2l—wD2—nd2is2 therefore2
—2soE™—lled2“legisl—tive2 findingF42fe™—use2the2 ƒyer2evts’2proposed2finding2ot2
f—™t2 num˜er2RP2 refle™ts2 —2 misinterpret—tion2 —nd2 gross2 mis—ppli™—tion2 of2„ex—s2
wedi™—id2poli™yD2the2ixe™utive2gommissioner2h—s2™omplete2dis™retion2to2 modify2
the2proposed2findingF2 „exF2 hep’t2of2vi™ensing282‚egul—tion2vF2 „hompsonD2 PHIQ2
‡v2QUWIRVTD2 —t2 BT2 @“9en2—gen™y2enjoys2 ™omplete2 dis™retion2 in2 modifying2—n2
evt9s2findings2—nd2™on™lusions2when2those2findings2—nd2™on™lusions2refle™t2—2l—™k2
of2 underst—nding2 or2 mis—ppli™—tion2 of2 the2 existing2 l—wsD2 rulesD2 or2 poli™iesF”2
@quoting2ƒmith2vF2 wontem—yorD2PHHQ2 ‡v2
PIRHISWID2—t2BPTEPU2@emph—sis2—ddedAAY2
„exF2@“ov’t2gode2§2PH@AIFHSV@eA@IAF2
„he2ixe™utive2 gommissioner2modifies2€roposed2 pop2xoF2 RP2 for2 two2re—sonsF2
p2irstD2 the2 „w€€w’s2 dis™ussion2 of2 e™topi™2 eruption2 is2 —n2 instru™tionD2 not —2
definitionF2„his2error2refle™ts2—2misinterpret—tion2of2l—w2—nd2poli™y2˜y2the2ƒyer2
evtsF2ƒee2„exF2qov‘t2gode2§2 PHHIFHSV@eA@IAY2 „hompsonD2PHIQ2‡v2QUWIRVTD2—t2
BTY2ƒouthwest2€h—rntD2RHV2ƒF‡FQd2—t2SSUESVF2
ƒe™ondD2 the2 proposed2 finding2erroneously2 suggests2th—t2 it2 w—s2„ex—s2wedi™—id2
poli™y2 to2 —dopt2 —2 distin™t2 “definition”2 of2e™topi™2 eruption2 in2 the2 „w€€w2th—t2
differed2 from2 e™topi™2 eruption2 —s2 gener—lly2 understood2 within2 the2 dent—l2
professionF2„he2ƒyer2 evts’2proposed2finding2would2viol—te2st—te2—nd2feder—l2l—w2
˜e™—use2 ™re—tion2 of2—2 different2 set2 of2 st—nd—rds2 —ppli™—˜le2 only2 to2 wedi™—id2
p—tients2would2viol—te2˜oth2„ex—s2—nd2feder—l2l—wF2ƒeeD2eF2gFD2 l2 „exF2edminF2gode §2
QSRFI2IQI@hAY2 see2—lso2‚F‚F2†olF2 QD2 PSHXVEIWY2ixF2‚EIR2@PHHV2„w€€wAD2§2 IFPFSY2
ixF2 ‚EIS2 @PHHW2 „w€€wAD2 §2 IFRFS2 @“gompli—n™e2 with2 peder—l2 vegisl—tionF2
‚eminderX2 i—™h2provider2 must2furnish2 ™overed2wedi™—id2servi™es2 in2 the2 some2
m—nnerD2to2the2s—me2extentD2 —nd2of2the2s—me2qu—lity2—s2servi™es2provided2to2other2
p—tientsF2 ƒervi™es2 m—de2—v—il—˜le2 to2 other2p—tients2 must2˜e2 m—de2—v—il—˜le2 to2
„ex—s2 wedi™—id2 ™lients2 the2 servi™es2 —re2 ˜enefits2 of2the2 „ex—s2 wedi™—id2
€rogr—m”AF2end2in2 f—™tD2 —ll2 pu˜lished2poli™y2do™uments2promulg—ted2˜y2rrƒg2
require2 providers2to2 —pply2the2 s—me2st—nd—rds2of2™—re2 to2 wedi™—id2p—tients2they2
—pply2with2the2popul—tion2—t2 l—rgeF2 ƒeeD2 eFgFD2 ixF2‚EITD2—t2 §2 IFTY2 ixF2‚EISD2§2 IWFPF2
„he2w—nu—ls2didD2 in2 f—™tD2 instru™t2providers2to2use2their2tr—ining2—nd2edu™—tion2in2
the2tre—tment2of2wedi™—id2p—tients2—nd2to2tre—t2those2p—tients2 in2the2s—me2m—nner2
—s2 other2 p—tientsF2 ixF2 ‚EIS2 @PHHW2 „w€€wAD2 §2 IFRFSF2 „he2 ixe™utive2
gommissioner2is2 therefore2—uthorized2to2 ™orre™t2this2error2˜y2the2evtsF2 ƒee2„exF2
@Iov‘t2gode2§2PHHIFHSV@eA@I‘2 AF2 @QA2@—llowing2—n2—gen™y2to2™h—nge2—2€ph2 to2™orre™t2
errors2of2l—w2or2poli™y2or2 te™hni™—l2errors2in2—2proposed2finding2of2f—™tAF
PH
001763
„he2ƒyer2elFts2—lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2p—rti™ul—rlyD2 pop2PWD2 QID2 —nd2QQD2 for2their2underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2 gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2l—w2—nd2 wedi™—id2poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2§2PHHI2FHSV@eA@PAF2
en2—™™ur—te2underst—nding2of2the2s™ope2—nd2limit—tions2of2„ex—s2wedi™—id2poli™y2
out™ome2of2this2 disputeF2 „he2fund—ment—l2—lleg—tion2
is2 ™riti™—lly2 import—nt2to2the2
˜rought2˜y2the2snspe™tor2qener—l2is2 th—t2ehg2h—s2su˜mitted2™l—ims2for2€e2—nd2for2
reim˜ursement2th—t2—re2not2—uthorized2under2wedi™—id2poli™y2or2„ex—s2l—wF2„hese2
—lleg—tions2™—nnot2˜e2properly2ev—lu—ted2if2the2finder2of2f—™t2 does2not2underst—nd2
the2 poli™yF2 „hereforeD2 there2 is2 —2 r—tion—l2 ™onne™tion2 ˜etween2 the2 ™orre™t2
—rti™ul—tion2 of2wedi™—id2poli™y2—nd2the2 —ltered2finding2of2f—™tD2 whi™h2—™™ur—tely2
refle™ts2th—t2poli™yF2ƒeeD2eFgFD2 rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2esso™F2 vF2
„giD2QWQ2ƒF‡FQd2—t2RRHERIY2ƒt—te2vF2 widEƒouth2€—yersD2srt™FD2 PRT2ƒF‡FQd2—t2UPVY2
vevy2vF2 „exF2ƒt—te2f—’2 fwe—GF2ix—m2’rsD2 WTT2ƒF‡FPd2—t2VITF2
F2
efter2rrƒgEysq2imposed2the2 p—yment2hold2 on2ehgF2it2 hired2v—rry2„—dlo™kD2
hFhFƒF2 —n2 orthodontistD2 to2 review2the2 TQ2 p—tients2 previously2reviewed2 ˜y2hrF2
•F2
iv—nsF2
efter2 reviewing2 the2 p—tients’2 rvh2s™ore2 sheetsD2 hrF2 „2
—dlo™k2 found2 only2 one2
p—tientD2€—tient2ISD2who2met2the2PTEpoint2thresholds2
sn2reviewing2the2TQ2 ehg2p—tient2files2in2the2st—tisti™—lly2v—lid2r—ndom2s—mpleD2
hrF2 „—dlo™k2 —pplied2 the2 definition2 of2 e™topi™2 eruption2 th—t2 is2 gener—lly2
re™ognized2within2the2dent—l2profession2—nd2s™ored2the2p—tients2—s2instru™ted2
˜y2the2w—nu—lsF2hrF2„—dlo™k2properly2—pplied2wedi™—id2poli™yF2
@„he2 ƒyer2evts‘2 proposed2IIop2 xoF2 RS2 st—tedX2 hrF2 „—dlo™k2did2not2 —pply2the2
e™topi™2eruption2in2s™oring2the2rvh2index2for2the2TQ2ehg2
llG‘—nn—ls2 definition2of2
’2
p—tientsF A2
‚e—son2for2gh—ngeX2
€roposed2finding2of2f—™t2num˜er2RS2—ddresses2—2mixed2question2of2f—™t2—nd2l—wD2
—nd2 is2 —2 “legisl—tive2 findingF”2 „he2 ixe™utive2 gommissioner2 h—s2 ™omplete2
dis™retion2to2modify2the2proposed2findingF2 „exF2 hep’t2of2vi™ensing282‚egul—tion2
vF2 „hompsonD2 PHIQ2‡v2 QUWIRVTD2—t2BT2@“en2—gen™y2enjoys2™omplete2dis™retion2
in2 modifying2 —n2 evt9s2 findings2 —nd2 ™on™lusions2 when2 those2 findings2 —nd2
™on™lusions2refle™t2—2l—™k2of2underst—nding2or2mis—ppli™—tion2of2the2existing2l—wsD2
••••••••2
fy2letter2d—ted2t—nu—ry2 ITD2 PHIRF2the2ƒyer2G’vts2replied2to2the2osnspe™tor2@tener—l92s2 Fx™eptions2
IEX‘2
—nd2notified2the2ixe™utive2gommissioner2th—t2their2origin—l2proposed2finding2of2f—™t2num˜er2RR2should2˜e2
reused2 „he2lEvxe™utive2 gommissioner2—dopts2the2 elEFls’2 re™ommend—tions2reg—rding2revised2proposed2
lmding2of2f—™t2num˜er2RRF2
I
001764
rulesD2or2poli™iesF”92@quoting2ƒmith2vF2wonteGn—yorD2PHHQ2 ‡v2PIFRHISWID2—t2BPTEPU2
@emph—sis2—ddedAAY2„exF2qov’t2gode2§2PHHI2FHSV@eA@lAF2
„he2ixe™utive2 gommissioner2modifies2€roposed2pop2xoF2 RS2 for2 two2re—sonsF2
pirstF2 the2 „w€€w’s2 dis™ussion2 of2 e™topi™2 eruption2 is2 —n2 instru™tionD2 not —2
definitionF2„his2error2refle™ts2—2misinterpret—tion2of2l—w2—nd2poli™y2˜y2the2ƒyer2
evtsF2ƒee2„exF2qov”t2gode2§2 PHHIFHSV@eA@lAY2„hompsonD2PHIQ2 ‡v2QUWIRVTD2—t2
BTY2ƒouthwest2€h—rmFD2RHV2ƒF‡FQd2—t2SSUESVF2
ƒe™ondD2 the2 proposed2 finding2erroneously2 suggests2 th—t2 it2 w—s2„ex—s2wedi™—id2
poli™y2 to2 —dopt2—2 distin™t2 “definition”2 of2e™topi™2 eruption2 in2 the2 „w€€w2th—t2
differed2 fiom2 e™topi™2 eruption2 —s2 gener—lly2 understood2 within2 the2 dent—l2
professionF2„he2ƒyer2 evts92proposed2finding2would2viol—te2st—te2—nd2feder—l2l—w2
˜e™—use2 ™re—tion2 of2—2 different2 set2 of2 st—nd—rds2 —ppli™—˜le2 only2 to2 wedi™—id2
p—tients2would2viol—te2˜oth2„ex—s2—nd2feder—l2l—wF2ƒeeD2 eF2gFD2 I2 „exF2edminF2gode §2
QSRFIlQl@hAY2see2—lso2 ‚F‚FD2†olF2 QD2 PSHXVEIWY2ixF2 ‚EIR2@PHHV2„w€€wAF2§2 IFPFSY2
ixF2 ‚EIS2 @PHHW2 „w€€wAD2 §2 IFRFS2 @“gompli—n™e2 with2 peder—l2 vegisl—tionF2
‚eminderX2i—™h2provider2 must2furnish2 ™overed2wedi™—id2servi™es2 in2 the2 s—me2
m—nnerD2to2the2s—me2extentD2 —nd2of2tlze2 s—me2qu—lity2—s2servi™es2provided2to2other2
p—tientsF2 ƒervi™es2 m—de2—v—il—˜le2 to2 other2p—tients2 must2˜e2 m—de2 —v—il—˜le2 to2
„ex—s2 wedi™—id2 ™lients2 if2 the2 servi™es2 —re2 ˜enefits2 of2the2 „ex—s2 wedi™—id2
€rogr—m”AF2end2in2f—™tD2 —ll2 pu˜lished2poli™y2do™uments2promulg—ted2˜y2rrƒg2
require2 providers2 to2 —pply2the2 s—me2st—nd—rds2of2™—re2to2 wedi™—id2p—tients2 they2
—pply2with2the2popul—tion2—t2l—rgeF2ƒeeD2 eFgFD2 ixF2‚EITD2—t2§2 IFTY2 ‚EISD2§2 IWFPF2
elsoD2 the2 proposed2 finding2 mis™onstrues2 hrF2 „—dlo™l``92s2 testimonyF2 sn2 f—™tD2 hrF2
9l4—dlo™k’s2 testimony2 shows2 th—t2 in2 his2 viewD2 the2 w—nu—l‘s2 instru™tions2 —re2
™onsistent2with2the2gener—lly2understood2definition2of2e™topi™2eruptionF2‚F‚FD2†olF2
lD2 PHPIPIEPHQXIHF2„his2error2refle™ts2—2misinterpret—tion2of2
l—w2—nd2poli™y2˜y2the2
ƒyer2evFssD2 —2 misinterpret—tion2 th—t2 resulted2 in2 mis™onstruing2 hrF2 „—dlo™k’s2
testimonyF2„exF2qov’t2gode2§2PHHlFHSV@eA@lAF2
„he2ƒyer2evls2—lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 pop2PWD2 QID2 —nd2QQD2 for2their2underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2 gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2of2„ex—s2 l—w2—nd2wedi™—id2poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 qov’t2gode2§2PHHIFHSV@eA@PAF2
en2—™™ur—te2underst—nding2of2the2s™ope2—nd2limit—tions2of2„ex—s2wedi™—id2poli™y2
out™ome2of2this2 disputeF2„he2fund—ment—l2—lleg—tion2
is2 ™riti™—lly2 import—nt2to2 the2
˜rought2˜y2the2snspe™tor2qener—l2is2 th—t2ehg2h—s2su˜mitted2™l—ims2for2€e2—nd2for2
reim˜ursement2th—t2—re2not2—uthorized2under2wedi™—id2poli™y2or2„ex—s2l—wF2„hese2
—lleg—tions2™—nnot2˜e2properly2ev—lu—ted2if2the2tinder2of2f—™t2does2not2underst—nd2
the2 poli™yF2 „herel’oreD2 there2 is2 —2 r—tion—l2 ™onne™tion2 ˜etween2 the2 ™orre™t2
—rti™ul—tion2of2wedi™—id2poli™y2—nd2the2 —ltered2 finding2of2f—™tD2 whi™h2—™™ur—tely
4U
001765
refle™ts2th—t2poli™yF2ƒeeD2eFgFD2 rerit—ge2on2the2ƒ—n2
q—˜riel2romeowners2esso™F2 vF2
„giD2QWQ2ƒF‡FQd2—t2RRHER|Y2ƒt—te2vF2 widEƒouth2€oversD2In™FD2 PRT2ƒF‡FQd2—t2
UPVY2
vevy2vF2 „exF2ƒt—te2fdF2of2
wedF2ix—m rsD2WTT2ƒF‡FPd2—t2VITF2
’2
hespite2 the2ƒyer2evts2finding2hrF2 x—z—ri’s2
x2—z—ri2did2not2properly2follow2wedi™—id2poli™y2testimony2 to2 ˜e2™redi˜leD2 hrF2
in2his2identifi™—tion2of2e™topi™2
eruptionsY2 the2 overwhelming2eviden™e2of2the2 ™onsistent2
p—ttern2 of2infl—ted2
rvh2s™ores2 su˜mitted2 ˜y2 ehg2est—˜lishes2 prim—2 f—™ie2 eviden™e2 th—t2 is2
reli—˜leD2 relev—nt2 —nd2 m—teri—l2 th—t2 ehg‘s2
misrepresent—tions2 of2 medi™—l2
ne™essity2™onstitute2willful2misrepresent—tionsF2
@„he2ƒyer2evts’2proposed2pp2xoF2RT2st—tedX2hrF2x—z—ri2
w—s2—2™redi˜le2witness2
—nd2properly2utilized2the2w—nu—ls2 definition2in2s™oring2the2rvh2
’2
indexFA2
‚e—son2for2gh—ngeX2
€roposed2pop2xoF2RT2—ddresses2—2mixed2question2of2f—™t2
—nd2l—wD2—ndD2—s2su™hD2is —2
soE™—lled2 “legisl—tive2 findingF42 „hereforeD2 the2
ixe™utive2 gommissioner2 h—s2
™omplete2 dis™retion2 to2 modify2 itF2 „exF2 hep9t2
of2vi™ensing2 82‚egul—tion2 vF2
„hompsonD2 PHIQ2‡v2QUWIRVTD2—t2 BT2@“en2—gen™y2enjoys2
™omplete2dis™retion2in2
modifying2—n2evt9s2findings2—nd2™on™lusions2when2those2findings2
—nd2™on™lusions2
refle™t2 —2l—™k2 of2underst—nding2 or2 mis—ppli™—tion2
of2the2 existing2 l—wsD2 rulesD2 or2
poli™iesF4’2 @quoting2 ƒmith2 vF2
wontem—yorD2 PHHQ2 ‡v2PIRHISWID2 —t2 BPTEPU2
@emph—sis2—ddedAAX2„exF2qov’t2gode2§2PHHIFHSV@eA@lAF2
„he2 ixe™utive2 gommissioner2modifies2€roposed2pHI‘2 xoF2
RT2 for2 two2 re—sonsF2
pirstD2 the2 9I‘w€€w’s2 dis™ussion2 of2 e™topi™2
eruption2 is2 —n2 instru™tionD2 not —2
definitionF2 ƒeeD2 eFgFD2 ‚F‚FD2 †olF2 l2 —t2 IHQXVEIP2
@terms2 in2 the2 e™topi™2 eruption2
instru™tion2—re2not2defined2˜ut2—re2—™™orded2their2
pl—in2 —nd2ordin—ry2me—ning2in2
the2inglish2l—ngu—geAY2 ‚F‚FD2†olF2 I2 —t2 ll2IX2 IPEIR2
@providers2must2underst—nd2the2
m—nu—l2 ˜y2 virtue2 of2 their2 profession—l2 tr—iningAF2
„his2 error2 refle™ts —2
misinterpret—tion2of2l—w2—nd2poli™y2˜y2the2 ƒyer2 evtsF2ƒee2„exF2 qov’t2gode §2
82
PHHlFHSV@eA@lAY2 „exF2 hep9t2of2vi™ensing2 ‚egul—tion2 vF2
„hompsonD2 PHIQ2 ‡v2
QUWIRVTD2—t2BTY2ƒouthwest2€h—rmFD2RHV2ƒF‡FQd2—t2SSUESVF2
ƒe™ondD2 the2 proposed2 finding2erroneously2 suggests2 th—t2
it2 w—s2„ex—s2wedi™—id2
poli™y2 to2 —dopt2 —2distin™t2 “definition”2 of2e™topi™2
differed2 from2 e™topi™2 eruption2 —s2 gener—lly2
eruption2 in2 the2 „w€€w2 th—t2
understood2 within2 the2 dent—l2
professionF2„he2ƒyesEEs2evts’2proposed2finding2would2
viol—te2st—te2—nd2feder—l2l—w2
˜e™—use2 ™re—tion2 of2 —2 different2 set2 of2st—nd—rds2
—ppli™—˜le2 only2 to2 wedi™—id2
p—tients2would2viol—te2˜oth2„ex—s2—nd2feder—l2l—wF2
ƒeeF2 eFgFD2 I2 „exF2edminF2gode
§2
QSRFIlQl@hAX2 see2—lso2 ‚‚FD2 †olF2 QD2 PSHXVEIWY2 ixF2 ‚EIR2
@PHHV2„w€€wAD2§2 IFPFSY2
ixF2 ‚EIS2 @PHHW2 „w€€wAD2
§2 IFRFS2 @“gompli—n™e2 with2 peder—l2 vegisl—tionF2
‚eminderX2 i—™h2provider2must2fitrnish2 ™overed2wedi™—id2
servi™es2 in2 the2 s—me2
m—nnerD2to2the2some2extentD2 —nd2of2the2s—me2qu—lity2—s2
servi™es2provided2to2other2
p—tientsF2 ƒervi™es2 m—de2—v—il—˜le2 to2 other2
p—tients2 rnust2 ˜e2 m—de2—v—il—˜le2 to
PQ
001766
„ex—s2 wedi™—id2 ™lients2 if2 the2 servi™es2 —re2 ˜enefits2 „ex—s2 wedi™—id2
of2the2
€rogr—G9nF4AF2 end2in2 f—™tD2 —ll2 pu˜lished2poli™y2do™uments2
promulg—ted2˜y2rrƒg2
require2providers2 to2 —pply2the2 s—me2st—nd—rds2 HI42™—re2 to2
wedi™—id2p—tients2 they2
—pply2with2the2popul—tion2—t2l—rgeF2ƒeeD2 eFgFD2 ixF2‚EITD2—t2 IFTY2 ixF2‚EISD2 IWFPF2
§2 §2
woreoverD2™ontr—ry2 to2 „ex—s2 wedi™—id2poli™y2 requirements2 th—t2 providers2
tre—t2
wedi™—id2p—tients2 to2 the2 s—me2st—nd—rd2 of2™—re2 —s2 the2 gener—l2
popul—tionD2 hrF2
x—z—ri2 testitied2 th—t2 orthodonti™s2 for2 wedi™—id2 p—tients2 is2
different2 th—n2
orthodonti™s2 for2 nonEwedi™—id2 p—tientsF2 ‚F‚FD2 †olF2
RD2 —t2 IHQIIQEITD2 IHRXI—RD2
IRSXW—IHF2 purtherD2 hrF2 x—z—ri2 w—s2 un—˜le2 to2 define2 —2 “severe2
h—ndi™—pping2
m—lo™™lusionF”2l—’2 —t2lRRXlUE2IRSXTF2„his2testimony2refle™ts2
F2
th—tD2though2hrF2x—z—ri2
m—y2˜e2viewed2˜y2the2finder2of2f—™t2—s2™redi˜leD2hrF2x—z—ri2w—s2un—˜le2to2properly2
—pply2„ex—s2wedi™—id2poli™y2to2the2s™oring2of2p—tientsF2
„he2 ƒyer2evts2—lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 pop2PWD2 QID2 —nd2QQD2 for2their2underst—nding2
of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2
gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2
they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2l—w2—nd2
wedi™—id2poli™yD2 —nd2
thereforeF2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2
§2PHHlFHSV@eA@PAF2
„he2proposed2finding2refle™ts2—2fund—ment—l2misunderst—nding2—nd2
mis—ppli™—tion2
of2„ex—s2wedi™—id2poli™y2˜y2the2 ƒyer2G’vFlsF2 en2—™™ur—te2
underst—nding2of2the2
s™ope2 —nd2 limit—tions2 of2„ex—s2 wedi™—id2 poli™yis2 ™riti™—lly2
import—nt2 to2 the2
out™ome2of2this2 disputeF2 „he2fund—ment—l2 —lleg—tion2 ˜rought2
˜y2the2 snspe™tor2
qener—l2is2 th—t2ehg2h—s2su˜mitted2™l—ims2por2€e2—nd2for2reim˜ursement2
th—t2—re2
not2—uthorized2under2wedi™—id2poli™y2or2„ex—s2l—wF2 „hese2
—lleg—tions2 ™—nnot2˜e2
properly2ev—lu—ted2if2the2f—™t2finder2does2not2properly2interpret2—nd2
—pply2—2poli™yF2
„hereforeD2 there2 is2 —2 r—tion—l2 ™onne™tion2 ˜etween2 the2 ™orre™t2
—rti™ul—tion2 ot2
wedi™—id2poli™y2 —nd2the2 —ltered2 finding2of2f—™tD2 whi™h2—™™ur—tely2
refle™ts2 th—t2
poli™yF2ƒeeD2eF2gFD2 Frerit—ge2on2the2ƒ—n2q—˜riel2romeowners2
esso™F2 vF2 „2giD2QWQ2
ƒF‡FQd2RIUD2 RRHERI2 @„exF2 eppF—eustin2PHIPD2 pet2 deniedAY2 ƒt—te2 vF2
widEƒouth2
€—versD2In™FF2 PRT2ƒF‡FQd2UIID2UPV2@„exF2eppF—eustin2PHHUD2
petF2 deniedAY2vevy2vF2
„exF2 ƒt—te2felF2 ofllGledF2 ix—m’2
rsD2 WTT2ƒF‡FPd2VIQD2 VIT2@„exF2 eppF—euslin2
IWWVD2
no2p™tAF2
hespite2the2ƒyer2evts2finding2hrF2 u—n——n’s2testimony2to2
˜e2™redi˜leD2 hrF2
u—n——n2 did2 not2 properly2 follow2 wedi™—id2 poli™y2 in2 his2 identifi™—tion2
of2
e™topi™2 eruptionsY2 the2 overwhelming2 eviden™e2 of2 the2
™onsistent2 p—ttern2 of2
infl—ted2rvh2s™ores2su˜mitted2˜y2ehg2est—˜lishes2prim—2f—™ie2
eviden™e2th—t2
is2 reli—˜leD2 relev—nt2 —nd2m—teri—l2
th—t2ehg‘s2misrepresent—tions2of2medi™—l2
ne™essity2™onstitute2willful2misrepresent—tionsF2
@„he2 ƒyer2evts’2 proposed2 pop2 xoF2 PQ2 st—tedX2 ‡—el2 u—n——nD2
hFhFƒF2 —n2
who2worked2with2ehg2w—s2—2™redi˜le2witness2—nd2properly2utilized’2
HrtlzH—9orztz9st2
the2w—nu—ls2 —lefinition2ofe™topi™2eruption2in2s™oring2
the2rvh2indexFA
’2
PR
001767
‚e—son2for2gh—ng2
eX2
€roposed2pop2xoF2RU2 —ddresses2 —2 mixed2question2of2f—™t2 —nd2l—wD2 —nd2is2 —2 soE2
™—ll™d2“legisl—tive2 findingF“2„hereforeD2the2ixe™utive2gommissioner2h—s2™omplete2
dis™retion2to2modify2itF2 „exF2 hep9t2of2vi™ensing282‚egul—tion2vF2 „hompsonD2 PHIQ2
‡v2QUWIRVTD2—t2 BT2 @“‘en2—gen™y2enjoys2 ™omplete2 dis™retion2 in2 modifying2—n2
evt‘s2findings2—nd2™on™lusions2when2those2findings2—nd2™on™lusions2refle™t2—2l—™k2
of2 underst—nding2 or2 mis—ppli™—tion2 of2 the2 existing2 l—wsD2 rulesD2 or2 poli™iesF”2
@quoting2ƒmith2vF2 wontem—yorD2PHHQ2‡v2PIRHISWID2—t2BPTEPU2@emph—sis2—ddedAAY2
„exF2qov’t2gode2§2PHHlFHSV@eA@lAF2
„he2ixe™utive2gommissioner2modifies2€roposed2pop2xoF2RU2for2three2 re—sonsF2
pirstD2the2 „w€€w’s2 dis™ussion2 of2 e™topi™2 eruption2 is2 —n2 instru™tionD2 not —2
definitionF2 ƒeeD2 eFgFD2 ‚F‚FD2 †olF2 l2 —t2 IHQXVEIP2 @terms2 in2 the2 e™topi™2 eruption2
instru™tion2—re2 not2defined2˜ut2—re2 —™™orded2their2pl—in2—nd2ordin—ry2me—ning2in2
the2inglish2l—ngu—geAY2‚F‚FD2†olF2 I2 —t2 lllX2 IPEIR2@providers2must2underst—nd2the2
m—nu—l2 ˜y2 virtue2 of2 their2 profession—l2 tr—iningAF2 „his2 error2 refle™ts —2
misinterpret—tion2of2l—w2—nd2poli™y2˜y2the2 ƒyer2 evtsF2ƒee2„exF2qov9t2gode §2
PH@AIFHSV@™A@lAY2 „hompsonD2PHIQ2 ‡v2 QUWIRVTD2 —t2 BTY2 ƒouthwest2€h—rntD2 RHV2
ƒF‡FQd2—t2SSUESVF2
ƒe™ondD2 the2 proposed2 finding2erroneously2 suggests2 th—t2 it2 w—s2„ex—s2wedi™—id2
poli™y2 to2 —dopt2—2 distin™t2 “definition”2 of2e™topi™2 eruption2 in2 the2 „l’G{€€w2 th—t2
differed2 from2 e™topi™2 eruption2 —s2 gener—lly2 understood2 within2 the2 dent—l2
professionF2„he2ƒyG’IIevls’2proposed2finding2would2viol—te2st—te2—nd2feder—l2l—w2
˜e™—use2 ™re—tion2 of2 —2 different2 set2 of2st—nd—rds2 —ppli™—˜le2 only2 to2 wedi™—id2
p—tients2would2viol—te2˜oth2„ex—s2—nd2feder—l2l—wF2ƒeeF2 eFgFD2 I2 „exF2edminF2gode §2
QSRFIIQl@hAY2see2—lso2‚‚FD2†olF2QD2 —t2PSHXVEIWY2ixF2‚EIR2@PHHV2„w€€wAD2§2 IFPFSY2
‚EIS2 @PHHW2 „w€€wAD2 §2 IFRFS2 @“gompli—n™e2 with2 peder—l2 vegisl—tionF2
‚eminderX2 i—™h2provider2must2furnish2 ™overed2wedi™—id2servi™es2 in2 the2 s—me2
m—nnerD2 to2the2s—me2extentD2 —nd2of2the2s—me2qu—lity2—s2servi™es2provided2to2other2
p—tientsF2 ƒervi™es2 m—de2—v—il—˜le2 to2 other2p—tients2 must2˜e2 m—de2—v—il—˜le2 to2
„ex—s2 wedi™—id2 ™lients2 if2 the2 servi™es2 —re2 ˜enefits2 of2the2 „ex—s2 wedi™—id2
€rogr—m”AF2end2in2 f—™tD2 —ll2 pu˜lished2poli™y2do™uments2promulg—ted2˜y2rsE{ƒg2
require2 providers2to2 —pply2the2 s—me2st—nd—rds2of2™—re2to2 wedi™—id2p—tients2they2
—pply2with2the2popul—tion2—t2l—rgeF2ƒeeD2 eFgFF2ixF2‚EITD2—t2§2 lFTY2ixF2‚EISD2§2 IWFPF2
por2ex—mpleD2 hrF2 u—n——n2testified2 th—t2 the2 word2“h—ndi™—pping”2 in2 the2 phr—se2
“severe2 h—ndi™—pping2m—lo™™lusion”2 me—ns2“extreme2 devi—tion2 from2the2 normF”2
‚F‚FD2†olF2QF2 —t2 IHIXQEVF2 ‰etD2 of2the2TQ2 p—tients2 in2 the2st—tisti™—lly2 v—lid2r—ndom2
s—mpleD2u—n——n2—greed2th—t2of2his2p—tients2he2s™ored2—t2le—st2seven2e™topi™2teeth2in2
e—™h2p—tientD2 —2r—te2 of2IHH7F2ldFD2 WUXSEVF2„his2testimony2relle™ts2th—tD2 though2hrF2
u—n——n2m—y2˜e2 viewed2 ˜y2the2 finder2of2f—™t2 —s2 ™redi˜leD2 hrF2 u—n——n2did2 not2
properly2—pply2„ex—s2wedi™—id2poli™y2to2the2s™oring2ofp—tientsF2
PS
Rs
001768
„hirdF2hrF2 u—n——n2s™ored2PQ2of2PU2p—tients2
ex—™tly2the2s—me2‡—y—with2the2s—me2
eight2 teeth2 ˜eing2 s™ored2 —s2 e™topi™F2 ‚EVQY2
†olF2 Q2 —t2 RQEUHF2 „he2
—™knowledged2 this2 undisputed2 eviden™eF2 €phD2 —t2
ƒyer2 evFls2
PSF2 „his2 eviden™e2 of2 hrF2
u—n——n‘s2p—ttern2 oi‘2 s™oring2is2 prim—2f—™ie2
eviden™e2th—t2 hrF2 u—n——n2—™ted2with2
requisite2knowledge2under2the2„wp€eF2
rumF2‚esF2gode2§2 QTFHHll@˜AF2 „he2
„exF2
ixe™utive2 gommissioner2 is2 —uthorizedD2 thereforeD2
to2 ™orre™t2 the2 ƒyer2evts‘2
errorF2„exF2qov’t2gode2§P@A@AIFHSV@eA@IAF2
„he2ƒyer2evt2 s2—lso2erred2to2the2extent2th—t2
they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 pop2PWD2 QID2 —nd2
QQD2 por2their2underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2
poli™yF2 „he2ixe™utive2 gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2
™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2
„ex—s2l—w2—nd2 wedi™—id2poli™yD2 —nd2
thereforeF2™—nnot2˜e2relied2onF2 „exF2qov’t2
gode2§2P@AHIFHSV@eA@PAF2
„he2proposed2finding2refle™ts2—2fund—ment—l2
misunderst—nding2—nd2mis—ppli™—tion2
of2„ex—s2l—w2—nd2wedi™—id2poli™y2 the2ƒyG’r2
˜y2 evtsF2en2—™™ur—te2underst—nding2
of2the2s™ope2—nd2limit—tions2of2„ex—s2wedi™—id2
poli™y2is2 ™riti™—lly2import—nt2to2the2
out™ome2 of2this2 disputeF2 „he2fund—ment—l2 —lleg—tion2
˜rought2 ˜y2the2 snspe™tor2
qener—l2is2 th—t2ehg2h—s2su˜mitted2™l—ims2for2€e2
—nd2for2reim˜ursement2th—t2—re2
not2 —uthorized2under2wedi™—id2poli™y2or2
„ex—s2l—wF2 „hese2—lleg—tions2™—nnot2˜e2
properly2ev—lu—ted2if2the2f—™t2finder2does2not2
properly2interpret2—nd2—pply2—2poli™yF2
„hereforeD2 there2 is2 —2 r—tion—l2 ™onne™tion2
˜etween2 the2 ™orre™t2 —rti™ul—tion2 ot2
wedi™—id2poli™y2 —nd2the2 —ltered2 finding2 of2f—™tD2
whi™h2—™™ur—tely2 refle™ts2 th—t2
poli™yF2ƒeeF2 eFgFD2 rerit—ge2on2the2ƒ—n2q—˜riel2
romeowners2esso™F2 vF2 „giD2QWQ2
ƒF‡FQd2RIUD2 RRHERI2 @„exF2 eppF—eustin2PHIPD2 pet2
deniedAY2 ƒt—te2 vF2 widEƒouth2
€—versD2In™FF2 PRT2ƒF‡FQd2UIID2UPV2@„exF2eppF—eustin2
PHHUD2petF2 deniedAY2vevy2vF2
„exF2 ƒt—te2fdF2HfwedF2ix—m2’rsD2 WTT2
ƒF‡FPd2VIQD2VIT2@„exF2eppF—eustin2IWWVD2no2
petFAF2
rrƒgEysq2presented2 eviden™e2th—t2 is2 ™redi˜leD2 reli—˜leD2 —nd2
th—t2h—s2indi™i—2of2reli—˜ility2when2
verifiedD2 —nd2
—n—lyzed2™onsistently2with2„ex—s2l—w2—nd2
wedi™—id2poli™yD2 th—t2 ehg2 knowingly2in™orre™tly2 s™ored2the2 rvh2
index2on2
orthodonti™2prior2—pprov—l2requests2su˜mitted2
to2„ex—s2wedi™—idF2
@„he2 ƒyer2evts’2 proposed2 sE4op2 xoF2 RV2 st—tedX2
„here2 is2 no2 eviden™e2 th—t2 is2
™redi˜leD2 reli—˜leD2 or2 verifi—˜leD2 or2 th—t2
h—s2 indi™i—2 of2reli—˜ilityD2 th—t2 ehg2
in™orre™tly2s™ored2the2rvh2sndex2to2 o˜t—in2
„ex—s2wedi™—id2˜enefits2for2p—tients2
or2to2o˜t—in2„ex—s2llG‘e™li™—i—92p—ymentsFA2
‚e—son2for2gh—ngeX2
€roposed2polc2 xoF2 RV2—ddresses2 —2mixed2question2
of2f—™t2 —nd2l—wD2 —nd2is2 —2soE2
™—lled2“legisl—tive2findingF”2 „hereforeD2
the2ixe™utive2gommissioner2h—s2™omplete2
82‚egul—tion2vF2 „hompsonD2 PHIQ2
dis™retion2to2 modify2itF2 „exF2 hep’t2G‘vi™ensiizg2
‡v2QUWIRVTD2 —t2 BT2 @“en2—gen™y2enjoys2 ™omplete2 dis™retion2 in2 modifying2 —n2
PT
9
001769
es•Ft9s2 findings2—nd2™on™lusions2whenF2those2
findings2—nd2™on™lusions2refle™t2—2l—™k2
underst—nding2 or2 mis—ppli™—tion2 oi’2 the2 existing2 l—wsD2 rulesD2 or2 poli™iesF”2
ol’2
@quoting2ƒmith2vF2wontem—yorD2PHHQ2‡sF2PlRHlSWlD2—t2BPTEPU2@emph—sis2
—ddedAAY2
„exF2qov’t2gode2§2PHHlFHSV@eA@lAF2
„he2ixe™utive2gommissioner2modifies2€roposed2pol’2xoF2RV2˜e™—use2the2 ƒyess2
es•ts2 misinterpreted2 —nd2 mis—pplied2„ex—s2l—w2—nd2wedi™—id2
poli™yF2 pirstD2 the2
proposed2finding2mis—pplies2l—w2—nd2wedi™—id2poli™y2˜y2st—ting2 th—t2 there2 is2 no2
eviden™e2th—t2ehg2in™orre™tly2s™ored2the2rvh2indexF2sn2f—™tD2 the2eviden™e2
shows2
th—t2the2rsh2s™ores2su˜mitted2˜y2hrsF2x—z—ri2—nd2u—n——n2
were2in™orre™t2˜e™—use2
of2their2interpret—tion2of2e™topi™2 eruptionF2 ƒeeD2 eFgFF2 testimony2of2hrF2
„—dloek2—t2
‚‚D2†olF2 lD2 —t2 IUQXQETY2 IURXTEIUSXIY2 lUTXlREPHY2 IUUXIEITY2see2—lso2testimony2of2
hrF2x—z—riD2‚‚D2†olF2RD2—t2 IRRXIcEIRSXTY2—nd2testimony2of2hrF2
u—n——nD2‚‚D2†olF2QD2
—t2RQEUHF2„he2tot—lity2of2the2eviden™eD2whi™h2in™ludes2the2
testimony2ot‘ehg‘2s2own2
witnessesD2 —s2 well2—s2 the2 snspe™tor2qener—l92s2 f—™t2 witnesses2—nd2expertsD2 is2
mu™h2
more2th—n2prim—2fiz™ieD2—nd2is2 relev—ntD2 ™redi˜le2—nd2m—teri—lF2ƒee2„exF2rumF2‚esF2
gode2§2QPFHPWI@™AF2
ƒe™ondD2 the2 proposed2 finding2 is2 erroneous2 ˜e™—use2 impli™it2 in2 it2 —re2
the2
—ssumptions2th—t2 the2 definition2of2e™topi™2 eruption2is2 wholly2open2to2 su˜je™tive2
interpret—tionF2 —nd2th—t2„ex—s2wedi™—id2—dopted2—24spe™i—l42definition2
of2e™topi™2
eruption2th—t2 w—s2more2li˜er—l2 th—n2 the2 gener—lly2—™™epted2definition2 of2
e™topi™2
eruption2in2the2orthodonti™2profession2@—nd2™ontr—ry2to2the2„w€€w’s2
instru™tion2
to2 providers2 to2 ˜e2 “™onserv—tive”2 in2 their2 s™oringAF2
„hese2 errors2 refle™t2
niisinterpret—tions2—nd2mis—ppli™—tions2of2l—w2—nd2wedi™—id2
poli™y2˜y2the2 ƒyess2
evtƒF2
„hirdD2hrF2u—n——n2s™ored2PQ2of2PU2p—tients2ex—™tly2the2s—me2‡—y—with2
the2s—me2
eight2teeth2 ˜eing2 s™ored2 —s2 e™topi™F2 ‚EVQY2 †olF2 Q2 —t2 RQEUHF2
purtherD2 the2ƒyer2
evts2—™knowledged2this2 undisputed2eviden™eF2€phD2—t2 PSF2 „his2eviden™e2of2hrF2
u—n——n’s2p—ttern2 of2s™oring2 is2 prim—2f—™ie2 eviden™e2th—t2 hrF2 u—n——n2
—™ted2with2
requisite2knowledge2under2the2 „wp€eF2„exF2 rumF2‚esF2gode2
§2 QTFHHI2l@˜AF2 „he2
ixe™utive2 gommissioner2 is2 —uthorizedD2 thereforeD2 to2 ™orre™t2 the2 ƒyer2evts’2
errorF2„exF2qov’t2gode2§2PHHlFHSV@™A@lAF2
pin—llyD2this2proposed2finding2refle™ts2—2further2mis—ppli™—tion2of2l—w2
in2suggesting2
th—t2the2snspe™tor2qener—l2˜e—rs2the2˜urden2of2proving2intent2
to2defr—ud2wedi™—idF2
es2 the2 ƒyess2evts2 —™knowledge2 in2 the2 n—rr—tive2 se™tion2 of2their2 €phD2 the2
snspe™tor2qener—l2does2not2h—ve2the2˜urden2to2show2spe™ifi™2intent2to2
defr—ud2the2
wedi™—id2progr—m2to2 show2th—t2 ehg2h—s2 ™ommitted2—n2unl—wful2—™t2 under2the2
„wp€eF2ƒee2€ph2—t2 lSD2™iting2definition2of2“knowingly”2—t2se™tion2QTFHHI2I2 ofthe2
„wp€eY2 see2 —lso2 gov2 xoF2 TD2 —t2 p—ge2 RP2 of2 the2 €ph2 @s—me2 propositionAF2
xeverthelessD2 in2 proposed2pop2xoF2RVD2the2 ƒyer2evts2write2 th—t2 the2
snspe™tor2
qener—l2 t—iled2 to2 present2 ™redi˜leD2 reli—˜leD2 or2 veriti—˜le2 eviden™e2
th—t2 ehg
PU
001770
in™orre™tly2s™ored2 rvh2indi™es2“to2o˜t—in2„ex—s2wedi™—id2˜enefits2for2p—tients2or2
to2o˜t—in2„ex—s2wedi™—id2
p—ymentsF”2
„he2˜urden2on2the2snspe™tor2qener—l2is2 only2to2demonstr—te2relev—ntD2™redi˜le2—nd2
m—teri—l2eviden™e2th—t2ehg2knowingly2su˜mitted2s™ores2th—t2overst—ted2the2™hild‘s2
true2 ™onditionF2 „exF2 rumF2 ‚esF2 gode2 §2 QPFHPWl@™AF2 hrsF2 u—n——n2 —nd2 x—z—ri2
—™knowledge2 they2 —pplied2 —n2 interpret—tion2 of2 e™topi™2 eruption2 th—t2 did2 not2
™omport2with2wedi™—id2poli™yF2„o2the2extent2the2ƒyer2evts2—ttempt2to2hold2the2
snspe™tor2qener—l2to2the2—ddition—l2˜urden2of2proving2intent2on2the2p—rt2of2ehg2to2
defr—ud2the2wedi™—id2progr—mD2proposed2pop2xoF2RV2is2erroneousF2
„he2ƒyer2evts2—lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 por‘2 PWD2QID2 —nd2QQD2 for2their2underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2 l—w2—nd2wedi™—id2poli™yD2 —nd2
thereforeF2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2§2PHHlFHSV@eA@PAF2
woreoverD2 the2 proposed2 finding2 refle™ts2 —2 fund—ment—l2 misunderst—nding2 —nd2
mis—ppli™—tion2of2„ex—s2l—w2—nd2wedi™—id2poli™y2˜y2the2ƒyer2evtsF2en2—™™ur—te2
underst—nding2of2the2s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™y2is2 ™riti™—lly2
import—nt2to2 the2 out™ome2of2this2 disputeF2 „hese2—lleg—tions2 ™—nnot2˜e2 properly2
ev—lu—ted2 if2the2 tinder2 of2f—™t2 does2 not2 properly2 interpret2 —nd2 —pply2 —2 poli™yF2
„hereforeD2 there2 is2 —2 r—tion—l2 ™onne™tion2 ˜etween2 the2 ™orre™t2 —rti™ul—tion2 ot2
wedi™—id2 poli™y2 —nd2the2 —ltered2 finding2 of2f—™tD2 whi™h2—™™ur—tely2 refle™ts2 th—t2
poli™yF2ƒeeD2eF2gFD2 rerit—ge2on2the2ƒ—n2q—˜riel2roineowners2esso™F2 vF2 „giD2QWQ2
ƒF‡FQd2RlUD2 RRHERI2 @„exF2 eppF—eustin2PHIPD2 pet2 deniedAY2 ƒt—te2 vF2 wid~ƒHuth2
€—versD2 In™FD2 PRT2ƒF‡FQd2Ul2lD2 UPV2@„exF2eppF—eustin2PHHUD2petF2 deniedAY2vexy2vF2
„exF2ƒt—te2felF2 Gw€TlF2ix—m29rsD2 WTT2ƒF‡FPd2VIQD2VIT2@„exF2eppF—eustin2IWWVD2no2
petFAF2
rrƒg~ylq2presented2prim—2f—™ie2 eviden™e2 th—t2 is2 ™redi˜leD2 reli—˜leD2 —nd2
verifiedD2 —nd2th—t2 h—s2indi™i—2 of2reli—˜ility2 when2—n—lyzed2™onsistently2 with2
„ex—s2 l—w2 —nd2 wedi™—id2 poli™yD2 th—t2 ehg2™ommitted2 fr—ud2 or2 willful2
misrepresent—tions2to2„ex—s2wedi™—idF2
@„he2 ƒyer2evts’2 proposed2po˜‘2 xoF2 RW2 st—tedX2 „here2 is2 no2 eviden™e2 th—t2 is2
™redi˜leD2 reli—˜leD2 or2 verifi—˜leD2 or2 th—t2 h—s2 indi™i—2 of2reli—˜ilityD2 th—t2 ehg2
™oGnmitl9ed•fi4—ud2or2eng—ged2in2 willful2 misrepresent—tion2with2respe™t2to2 the2 TQ2
ehg2p—tients2in2this2™—seFA2
‚e—son2por2gh—ngeX2
€roposed2polc2 xoF2RW2—ddresses2 —2mixed2question2of2f—™t2 —nd2l—wD2 —nd2is2 —2soE2
™—lled2“legisl—tive2findingF”2 „hereforeD2the2ixe™utive2gommissioner2h—s2™omplete2
o
dis™retion2to2modi4l’y2itF2 „exF2 hept2ofli™ensing282‚egul—tion2vF2 „hompsonD2 PHIQ2
‡v2QUWIRVTD2 —t2 BT2@49en2—gen™y2 enjoys2 ™omplete2 dis™retion2 in2 modifying2 —n2
PV
001771
evt‘s2findings2—nd2™on™lusions2when2those2findings2—nd2™on™lusions2
relle™t2—2l—™k2
oi’2 underst—nding2 or2
mis—pplie—tion2 of2 the2 existing2 l—wsD2 rulesD2 or2 poli™iesF”2
@quoting2ƒmitlz2vF2 wontem—yorD2PHHQ2 ‡v2PIRHISWID2—t2BPTEPU2@emph—sis2—ddedAAY2
„exF2qov’t2gode2§2PHHlFHSV@eA@lAF2
„he2ixe™utive2gommissioner2modifies2€roposed2polc2xoF2RW2˜e™—use2the2 ƒyer2
evss2misinterpreted2—nd2mis—pplied2„ex—s2l—w2—nd2wedi™—id2poli™yF2 pirstD2 the2
proposed2finding2mis—pplies2„ex—s2l—w2governing2the2snspe™tor2qener—l’s2˜urden2
of2proof2in2this2 ™—seF2 es2noted2in2 gov2xoF2 IPD2to2m—int—in2the2p—yment2holdD2the2
snspe™tor2 qener—l2 must2 only2 m—ke2—2prim—2f—™ie2 showing2 of2eviden™e2 th—t2 is2
™redi˜leD2 reli—˜le2 or2 verifi—˜leD2 or2 th—t2 h—s2 indi™i—2 of2reli—˜ility2 th—t2 ehg2h—s2
™ommitted2fr—ud2or2willful2misrepresent—tions2in2this2™—seF2
„he2 ƒyer2evts42 determin—tion2 th—t2 the2 snspe™tor2 qener—l2 presented2 “no2
eviden™e”2 on2 this2 issue2 is2 the2 result2 of2 the2 ƒyer2evts’2 leg—lly2
erroneous2
interpret—tion2of2wedi™—id2poli™y2with2respe™t2to2the2definition2of2e™topi™2
eruptionF2
es2the2snspe™tor2qener—l2noted2in2his2ix™eptionsD2the2ƒyesEs2evsƒ’2determin—tions2
th—t2 the2 following2 —re2 —ll2 errors2 in2 the2 interpret—tion2 —nd2 —ppli™—tion2
of2„ex—s2
wedi™—id2poli™y2—nd2l—wX2@IA2„ex—s2wedi™—id2“defined”2e™topi™2eruption2uniquely2
—nd2 differently2 in2 the2 „w€€w2th—n2 the2 gener—lly2 —™™epted2 definition2 in2 the2
orthodonti™2 professionY2 @PA2 th—t2 s—id2 definition2 w—s2wholly2 open2 to2 su˜je™tive2
interpret—tionY2 —nd2@QA2 th—t2 the2 PHIP2 ™h—nges2 to2 the2 „l’G‘€€w2“definition”2
were2
su˜st—ntive2r—ther2th—n2™l—rifyingF2
purtherD2 the2 ƒyesEs2 evts2 —lso2 mis—pplied2 l—w2 —nd2 poli™y2 to2 the2 following2
eviden™eD2 whi™h2 they2 themselves2 —™knowledgedX2 hrF2 u—n——n2 s™ored2 PQ2 of2PU2
p—tients2ex—™tly2the2s—me2w—y—Ewith2the2s—me2eight2teeth2˜eing2s™ored2—s2
e™topi™F2
‚EVQY2†olF2 Q2 —t2RQEUHF2„his2eviden™e2of2hrF2u—n——n’s2p—ttern2of2s™oring2is2 prim—2
f—eie2eviden™e2th—t2hrF2u—n——n2—™ted2with2requisite2knowledge2under2
the2 „wp€eF2
„exF2 sEEsumF2 ‚esF2 gode2§2 QTFHHII@˜AF2„he2ixe™utive2gommissioner2is2 —uthorizedD2
thereforeD2to2™orre™t2the2ƒyess2evts’2errorF2„exF2qov’t2gode2
§2PHHlFHSV@eA@lAF2
„he2ƒyer2evs2 s2 —lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2
p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 poil2 PWD2 QID2 —nd2QQD2 for2their2 underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2l—w2—nd2 wedi™—id2
poli™yF2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2 PHHI2FHSV@eA@PAF2
§2
woreoverD2 the2 proposed2 finding2 refle™ts2 —2 fund—ment—l2 misunderst—nding2 —nd2
mis—ppli™—tion2of2„ex—s2l—w2—nd2wedi™—id2poli™y2˜y2the2ƒyesEs2e9vtsF2en2—™™ur—te2
underst—nding2of2the2s™ope2—nd2limit—tions2of2„ex—s2wedi™—id2poli™y2is2 ™riti™—lly2
import—nt2to2the2 out™ome2of2this2 disputeF2 „he2fund—ment—l2—lleg—tion2˜rought2
˜y2
the2 snspe™tor2 qener—l2 is2 th—t2 ehg2 h—s2 su˜mitted2 ™l—ims2 for2
€e2 —nd2 for2
reim˜ursement2th—t2—re2not2—utltorized2under2wedi™—id2poli™y2or2„ex—s2l—wF2„hese2
—lleg—tions2™—nnot2˜e2properly2ev—lu—ted2if2the2de™ision2m—ker2does2not2
underst—nd
PW
001772
the2 poli™yF2 „hereforeD2 there2 is2 —2 r—tion—l2 ™onne™tion2 ˜etween2 the2 ™orre™t2
—rti™ul—tion2of2wedi™—id2poli™y2—nd2the2modified2finding2of2f—™tD2 whi™h2—™™ur—tely2
refle™ts2th—t2poli™yF2ƒeeD2eF2gFD2 rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2esso™F2vF2
„giD2QWQ2ƒF‡FQd2—t2RRHERIY2ƒt—te2vF2 widEƒouth2€—versD2sn™FD2 PRT2ƒF‡FQd2—t2UPVY2
vevy2vF2 „exF2ƒt—te2fzl2of2wedF2ix—m rsF2WTT2ƒF‡FPd2—t2VITF2
’2
rrƒgEysq2presented2prim—2f—™ie2 eviden™e2 th—t2 is2 ™redi˜leD2 reli—˜leD2 —nd2
verifiedD2—nd2th—t2h—s2indiei—2 of2reli—˜ility2 when2—n—lyzed2™onsistently2with2
„ex—s2 l—w2 —nd2 wedi™—id2 poli™yD2 th—t2 ehg2™ommitted2 fr—ud2 or2 willful2
misrepresent—tions2in2filing2requests2for2prior2—uthoriz—tion2with2 „wr€2for —2
su˜st—nti—l2m—jority2of2p—tients2in2the2ysq2—udit2s—mpleF2
@„he2 ƒyer2evts‘2 proposed2pop2xoF2 SH2 st—tedX2 „here2 is2 no2 eviden™e2 th—t2 is2
™redi˜leD2 reli—˜leD2 or2 verifi—˜leD2 or2 th—t2 h—s2 indi™i—2 of2reli—˜ilityD2 th—t2 ehg2
™ommitted2fi—tG™l2or2misrepresent—tion2 in2filing2requests2•Gor2prior2—uthoriz—tion2
with2„wr€for2the2TQ2p—tients2—t2issue2in2this2™—seFA2
‚e—son2for2gh—ngeX2
€roposed2pop2xoF2 SH2 —ddresses2 —2mixed2question2of2f—™t2 —nd2l—wD2 —nd2is2 —2 so~2
™—lled2“legisl—tive2findingF42„hereforeD2the2ixe™utive2gommissioner2h—s2™omplete2
82
dis™retion2to2modify2itF2 „exF2 hep9r2of2vi™ensing2 ‚egul—tion2vF2 „hompsonD2 PHIQ2
‡v2QUWIRVTD2 —t2 BT2 @“‘en2—gen™y2enjoys2 ™omplete2 dis™retion2 in2 modifying2—n2
evt9s2findings2—nd2™on™lusions2when2those2findings2—nd2™on™lusions2refle™t2
—2l—™k2
of2underst—nding2 or2 mis—ppli™—tion2 of2 the2 existing2 l—wsD2 rulesD2 or2 poli™iesF”2
@quoting2ƒmith2vF2wontem—yorD2PHHQ2 ‡v2
PIRHISWIF2—t2BPTEPU2@emph—sis2—ddedAAY2
„exF2qov’t2gode2§2PHHlFySV@eA@lAF2
„he2ixe™utive2gommissioner2modifies2€roposed2polc2 xoF2SH2˜e™—use2the2ƒyer2
evts2misinterpreted2 —nd2mis—pplied2„ex—s2l—w2—nd2wedi™—id2poli™yF2 pirstD2 the2
proposed2finding2mis—pplies2„ex—s2l—w2governing2the2snspe™tor2qener—l’s2˜urden2
of2proof2in2this2 ™—seF2es2noted2in2gov2xoF2 IPD2 to2m—int—in2the2p—yment2holdD2the2
snspe™tor2 qener—l2 must2 only2 m—ke2—2prim—2j—™ie2 showing2of2eviden™e2 th—t2 is2
™redi˜leD2 reli—˜le2 or2 verifi—˜leD2 or2 th—t2 h—s2 indi™i—2 of2reli—˜ility2 th—t2 ehg2
h—s2
™ommitted2fr—ud2or2willful2misrepresent—tions2in2this2™—seF2
„he2 ƒyer2evts’2 determin—tion2 th—t2 the2 snspe™tor2 qener—l2 presented2 “no2
eviden™e”2 on2 this2 issue2 is2 the2 result2 of2the2 ƒyesEs2 evts’2 leg—lly2
erroneous2
interpret—tion2of2wedi™—id2poli™y2with2respe™t2to2the2definition2of2e™topi™2eruptionF2
es2the2snspe™tor2qener—l2noted2in2his2ix™eptionsD2the2 ƒyer2 evt2s’2 determin—tions2
th—t2the2 following2—r™2 —ll2 errors2 in2 the2—ppli™—tion2of2„ex—s2wedi™—id2
poli™y2—nd2
l—wX2@IA2„ex—s2wedi™—id2“defined”2e™topi™2eruption2uniquely2—nd2differently2
in2the2
„w€€w2 th—n2the2gener—lly2—™™epted2definition2in2the2 orthodonti™2professionY2
@PA2
th—t2 s—id2definition2w—s2wholly2open2to2su˜je™tive2interpret—tionY2 —nd2
@QA2 th—t2 the2
PHIP2™h—nges2to2the2„w€€l’Gl2“definition”2were2su˜st—ntive2r—ther2th—n2™l—rifyingF
QH
001773
purtherD2 hrF2 u—n——n2s™ored2 PQ2 of2PU2p—tients2 ex—™tly2 the2 s—me2w—yE—vvit˜2 the2
s—me2eight2teeth2˜eing2s™ored2—s2e™topi™F2‚—VQY2†olF2Q2—t2RQEUHF2„he2ƒyer2evts2
—™knowledged2 this2 undisputed2 eviden™eF2 €phD2 —t2 PSF2 „his2 eviden™e2 of2 hrF2
u—n——n’s2p—ttern2 of2s™oring2is2 prim—2p—™ie2 eviden™e2th—t2 hrF2 u—n——n2—™ted2 with2
requisite2knowledge2under2the2„wp€eF2„exF2rumF2‚esF2gode2 QTFHHI2l@˜AF2 „he2
§2
ixe™utive2 gommissioner2 is2 —uthorizedD2 thereforeD2 to2 ™orre™t2 the2 ƒyer2evts’2
errorF2„exF2qov’t2gode2§2PHHIF@ASV@eA@lAF2
„he2ƒyer2evts2—lso2erred2to2the2extent2th—t2they2relied2on2tlIe2 r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 pyp2PWD2 QID2 —nd2QQD2 for2their2underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2 l—w2—nd2wedi™—id2poli™yD2 —nd2
thereforeF2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2 PH@AIFHSV@eA@PAF2
§2
woreoverD2 the2 proposed2 finding2 refle™ts2 —2 fund—ment—l2 misunderst—nding2 —nd2
mis—ppli™—tion2of2„ex—s2l—w2—nd2wedi™—id2poli™y2˜y2the2ƒ@Aer2evt2 sF2 en2
—™™ur—te2
underst—nding2of2the2s™ope2—nd2limit—tions2of2„ex—s2wedi™—id2poli™y2is2 ™riti™—lly2
import—nt2to2 the2out™ome2of2this2 disputeF2 „he2fund—ment—l2—lleg—tion2˜rought2˜y2
the2 snspe™tor2 qener—l2 is2 th—t2 ehg2h—s2 su˜mitted2 ™l—ims2 for2 €e2 —nd2 for2
reim˜ursement2th—t2—re2not2—uthorized2under2wedi™—id2poli™y2or2„ex—s2l—wF2„hese2
—lleg—tions2™—nnot2˜e2properly2ev—lu—ted2if2the2f—™t2finder2does2not2underst—nd2the2
poli™yF2„hereforeD2there2is2 —2r—tion—l2™onne™tion2˜etween2the2™orre™t2—rti™ul—tion2of2
wedi™—id2poli™y2—nd2the2 modified2finding2of2f—™tD2 whi™h2—™™ur—tely2 refle™ts2 th—t2
poli™yF2ƒeeF2eF2gFD2 rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2esso™F2 vF2 „giD2QWQ2
ƒF‡FQd2—t2 RRHERIY2ƒt—te2 vF2 llGsidEƒouth2 €—versD2 sn™D2 PRT2ƒF‡FQd2—t2 UPVY2 vevy2vF2
„exF2ƒt—te2f—’2HfwedF2ix—m2’rsD2 WTT2ƒF‡FPd2—t2VITF2
F2
SI2 ‡hen2IEsrƒgEysq2—rrived2—t2ehg2in2xovem˜er2llD2 PHIPF2—nd2—sked2for2TQ2™—se2
ehg2™ould2not2lo™—te2eight2dent—l2modelsD2
filesD2 prim—2f—™ie2eviden™e2exists2 th—t2
rvh2s™ore2sheetsD2—nd2two2preEtre—tment2x~r—ysF2
four2
SPF2 ehg2forw—rded2the2 lE{vh2s™ore2sheets2 —nd2supporting2do™ument—tion2to2 „l’G‘r€2
when2ehg2filed2its2 requests2for2prior2—uthoriz—tionF2
SQ2 rrƒgEysq2presented2prim—2f—™ie2eviden™e2th—t2ehg2f—iled2to2ret—in2these2re™ords2
—nd2models2for2the2required2five2ye—rsF2
SR2 rrƒgEysq2 presented2prim—2f—™ie2 eviden™e2 th—t2 is2 ™redi˜leD2 reli—˜leD2 —nd2
verifiedF2 —nd2th—t2 h—s2indi™i—2 of2reli—˜ility2 when2—n—lyzed2™onsistently2with2
„ex—s2 l—w2 —nd2 wedi™—id2 poli™yD2 th—t2 ehg2˜illed2 or2 ™—used2 ™l—ims2 to2 ˜e2
su˜mitted2to2„ex—s2wedi™—id2for2servi™es2or2items2th—t2—re2not2reim˜urs—˜le2
˜y2the2„ex—s2wedi™—id2progr—mF2
@„he2 ƒyesEs2 eFvts’2 proposed2 pop2 xoF2 SR2 st—tedX2 rrƒgEysq2f—iled2 to2 present2
prim—2f—™ie2evi™len™e2th—t2ehg2˜illed2Hr2™—used2™l—ims2to2 ˜e2su˜mitted2sH2 „ex—s
Q“
001774
llGledi™—i™lf˜r2servi™es2or2items2th—t2—re2not2reim˜urs—˜le2˜y2the2 „ex—s2wedi™—id2
progr—mFA2
‚e—son2for2gh—ngeX2
€roposed2pop2xoF2 SR2 —ddresses2 —2mixed2question2 of2f—™t2 —nd2l—wD2 —nd2is2 —2 soE2
™—lled2“legisl—tive2findingF42 „hereforeD2the2ixe™utive2gommissioner2h—s2™omplete2
dis™retion2to2modify2itF2 „exF2 hep9t2of2vi™ensing282‚egul—tion2vF2 „2 hompsonD2 PHIQ2
‡v2QUWIRVTD2 —t2 BT2 @“9G’n2 —gen™y2enjoys2 ™omplete2 dis™retion2 in2 modifying2—n2
G’vt9s2findings2—nd2™on™lusions2when2those2findings2—nd2™on™lusions2refle™t2—2l—™k2
ol‘2 underst—nding2 or2
mis—ppli™—tion2 of2 the2 existing2 l—wsD2 rulesD2 or2 poli™iesF”2
@quoting2ƒmith2vF2 woritem—yorD2PHHQ2 ‡v2
PIRHISWID2—t2BPTEPU2@emph—sis2—ddedAAY2
„exF2qov9t2gode2§2PHHIF…SV@eA@“AF2
„he2ixe™utive2gommissioner2modifies2€roposed2pop2xoF2SR2˜e™—use2it2 mis—pplies2
„ex—s2 l—w2 —nd2 wedi™—id2poli™yF2 lf2 the2 ƒyer2evts2h—d2 —pplied2 the2 proper2
w€€w2
st—nd—rd2 for2 e™topi™2 eruptionD2 ™onsistent2 with2 the2 „2 provision2 requiring2
providers2to2˜e2“™onserv—tive”2in2s™oringD2to2the2f—™ts2of2this2™—seD2then2the2ƒyer2
ev“2s2 would2h—ve2™on™luded2th—t2rrƒgEysq2presented2prim—2f—™ie2eviden™e2th—t2
in2—t2le—st2SV2of2the2TQ2™—ses2in2the2s—mple2ehg2su˜mitted2€e2requests2for2p—tients2
who2were2not2qu—lified2for2full2orthodonti—F2
„he2ƒyess2evts2—lso2orr™d2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 pop2PWD2 QID2 —nd2QQD2 for2their2underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2l—w2—nd2wedi™—id2poli™yD2 —nd2
thereforeF2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2§2PHHlFHSV@eA@PAF2
woreoverD2 the2 proposed2 finding2 refle™ts2 —2 fund—ment—l2 misunderst—nding2 —nd2
mis—ppli™—tion2of2„ex—s2l—w2—nd2wedi™—id2poli™y2˜y2the2ƒyer2ev•ssF2en2—™™ur—te2
underst—nding2of2the2 s™ope2—nd2limit—tions2of2„ex—s2wedi™—id2poli™y2is2 ™riti™—lly2
import—nt2to2 the2 out™ome2of2this2 disputeF2 „he2fund—ment—l2—lleg—tion2˜rought2˜y2
the2 lnspe™tor2 qener—l2 is2 th—t2 ehg2 h—s2 su˜mitted2 ™l—ims2 for2 €e2 —nd2 for2
reim˜ursement2th—t2—re2not2—uthorized2under2wedi™—id2poli™y2or2„ex—s2l—wF2„hese2
—lleg—tions2™—nnot2˜e2properly2ev—lu—ted2if2the2de™ision2m—ker2does2not2underst—nd2
the2 poli™yF2 „hereforeD2 there2 is2 —2 r—tion—l2 ™onne™tion2 ˜etween2 the2 ™orre™t2
—rti™ul—tion2of2wedi™—id2poli™y2—nd2the2modified2finding2of2f—™tD2 whi™h2—™™ur—tely2
refle™ts2th—t2poli™yF2ƒeeD2eFgFD2rerit—ge2on2the2ƒ—ri2 q—˜riel2romeowners2esso™F2 vF2
„giF2QWQ2ƒF‡FQd2—t2RRHERIY2ƒt—te2vF2 widEƒouth2€—veG‘sD2sn—D2PRT2ƒF‡FQd2—t2UPVY2
v€’{†2vF2 „exF2ƒt—te2felF2 HfFwedF2ix—m rsD2 WTT2ƒF‡FPd2—t2VITF2
‘2
ehg2™ommitted2progr—m2viol—tions2 when2 su˜mitted2 prior2—uthoriz—tion2
it2
requests2—nd2rvh2forms2for2hVHVH2™omprehensive2orthodonti™2tre—tmentD2of2
€—tients2ISD2STD2—nd2TH2when2these2p—tients2did2not2qu—lify2por2™omprehensive2
orthodonti™sF
QP
001775
@„he2 ƒyer2esFFts’2 proposed2 pop2xoF2 SS2 st—tedX2 €—tient2 sSD2 STD2 —nd2THD2 were2
eligi˜le2for2inter™eptive2tre—tment2under2„ex—s2wedi™—idFA2
‚e—son2for2gh—ng2
eX2
€roposed2pp2xoF2 SS2 —ddresses2 —2mixed2question2 of2f—™t2 —nd2l—wD2 —nd2is2 —2 soE2
™—lled2“legisl—tive2findingF”2 „hereforeD2the2ixe™utive2gommissioner2h—s2™omplete2
dis™retion2to2modify2itF2 „exF2 hep’t2of2vi™ensing282‚egul—tion2vF2 „hompsonD2 PHIQ2
‡v2QUWIRVTD2 —t2 BT2 @“en2—gen™y2enjoys2 ™omplete2 —9is™Ererion2 in2 modifying2—n2
G’vt9s2lindings2—nd2™on™lusions2when2those2findings2—nd2™on™lusions2refle™t2—2l—™k2
underst—nding2 or2 mis—ppli™—tion2 ol’2 the2 existing2 l—wsD2 rulesD2 or2 poli™iesF”2
oi‘2
@quoting2ƒmith2vF2 wontem—yorD2PHHQ2 ‡v2PIRHISWID2—t2BPTEPU2@emph—sis2—ddedAAY2
„exF2qov4t2gode2§2PHHIFHSV@eA@lAF2
„he2ixe™utive2gommissioner2modifies2€roposed2pop2xoF2SS2˜e™—use2it2mis—pplies2
„ex—s2l—w2—nd2wedi™—id2poli™yF2 „o2the2extent2the2ƒyer2evts2use2“inter™eptive”2
tre—tment2to2me—n2something2less2 th—n2™omprehensive2oithodonti™s2‘hVHVH“2@—nd2
therefore2 outside2 the2 requirement2th—t2 p—tients2 ˜e2 IP2 or2 older2or2h—ve2no2˜—˜y2
teethAD2 the2 ƒyer2evts2misst—te2 the2 eviden™eF2 ehg2˜illed2 the2 ™ode2hVHVH2for2
these2 p—tientsF2 me—ning2they2 f—lsely2 represented2to2 the2 st—te2 th—t2 these2 p—tients2
were2 IP2 or2older2or2h—d2lost2 —ll2 ˜—˜y2teethF2 „o2the2 extent2the2 ƒ@Aer2evts2use2
“inter™eptive”2to2 in™lude2™ode2hVHVHD2see2ix2‚EIS2—t2 §2 lWFlVFUD2they2—re2—g—in2in2
errorX2 hVHVH2is2expli™itly2not2—ppli™—˜le2to2p—tients2like2these2who2h—ve2˜—˜y2teeth2
—nd2—re2under2IP2ye—rs2oldF2
„hese2p—tients2 m—y2well2 h—ve2˜een2eligi˜le2 for2 inter™eptive2 tre—tment2—2th—t2 isD2
something2less2th—n2™omprehensive2orthodonti™s2—2˜ut2the2eviden™e2in2 this2 ™—se2is2
™le—rX2 ehg2˜illed2wedi™—id2for2—2—nd2represented2to2the2 ƒt—te2th—t2these2p—tients2
qu—lified2for2—2hVHVHD2or2™omprehensive2orthodonti™sF2 por2ex—mpleD2with2reg—rd2
to2 €—tient2 ISD2 the2 €€h2 st—tes2 th—t2 ehg2requested2 “prior2 —uthoriz—tion2 for2
inter™eptive2 tre—tmentF42 €ph2 —t2 QQF2 ehg2 requested2 hVHVHF2 ™omprehensive2
orthodonti™sF2for2this2p—tientD2even2though2the2p—tient2w—s2W2ye—rs2old2—nd2h—d2˜—˜y2
teethF2 €~lS2 —t2 €lS~HHIW2@ehg2€rior2euthoriz—tion2‚equest2porm2for2€—tient2
lS2 requesting2 “‘AVHVH”FA2 „his2 is2 —2 progr—m2 viol—tionF2 I2 „exF2 edminF2 gode §2
QUIF2lTlU@lA@uA2—nd2@SA@qAF2
‡ith2reg—rd2to2€—tient2STD2ehg2requested2hVHVH2™omprehensive2orthodonti™s2for2
this2p—tientF2even2though2the2p—tient2w—s2W2ye—rs2old2—nd2h—d2˜—˜y2teethF2ixF2€EST2
—t2 €STEHHIS2 @ehg2€rior2euthoriz—tion2‚equest2 porm2for2 €—tient2 ST2 requesting2
“hVHVH”2for2 —2™h—rge2of26UUSFHHFA2 „his2is2 —2progr—m2viol—tionF2 I2 „exF2edminF2
gode2§2Q’GIFlTlU@lA@uA2—nd2@SA@qAF2
ehg2
pin—llyD2 for2 €—tient2THF2 requested2hVHVH2™omprehensive2orthodonti™sD2even2
though2this2 p—tient2w—s2under2lP2—nd2h—d2˜—˜y2teethF2 ixF2€ETH2—t2 €THEHHHR@ehg2
€rior2euthoriz—tion2‚equest2porm2for2 €—tient2TH2requesting2“hVHVH”2for2—2™h—rge
QQ
001776
ol’6UUSFH@AFAF2 „his2is2 —2progr—m2viol—tionF2 l2 „exF2edminF2gode2 QUlFlTlU@IA@uA2
§2
—nd2@SA@qAF2
„he2p—™t2 th—t2 ehg2
˜illed2for2™omprehensive2orthodonti™s2when2their2p—tients2did2
not2qu—lify2for2th—t2tre—tment2is2—2progr—m2viol—tionD2—nd2w—rr—nts2—2p—yment2holdF2
„he2ƒyer2esFFts2—lso2erred2to2 the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 pop2PWD2 QID2 —nd2QQD2 for2 their2 underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 oi’2 „ex—s2 l—w2—nd2wedi™—id2poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov”X2gode2§2PH@AIFHSV@eA@PAF2
en2—™™ur—te2underst—nding2of2the2s™ope2—nd2limit—tions2of2„ex—s2wedi™—id2poli™y2
is2 ™riti™—lly2import—nt2 to2 the2 out™ome2 of2 —ny2 disputeF2 elleg—tions2 ™—nnot2 ˜e2
properly2ev—lu—ted2if2the2 de™ision2m—ker2does2not2properly2interpret2 —nd2—pply —2
poli™yF2„hereforeD2there2is2 —2r—tion—l2™onne™tion2˜etween2the2™orre™t2—rti™ul—tion2of2
wedi™—id2poli™y2 —nd2 the2 —ltered2 finding2of2f—™tD2 whi™h2—™™ur—tely2 refle™ts2 th—t2
poli™yF2ƒeeD2eFgFD2 rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2esso™F2 vF2 „giD2QWQ2
ƒF‡FQd2RIUD2 RRHERI2 @„exF2 eppF—eustin2PHIPD2pet2 deniedAY2 ƒl—te2 vF2 wi—’Eƒouth2
€—versD2sn™FD2 PRT2ƒF‡FQd2UIID2UPV2@„exF2eppF~eustin2PHHUD2petF2 deniedAY2vevy2vF2
wedF2ix—m2’rsD2 WTT2ƒF‡FPd2VIQD2VIT2@„exF2eppF—eustin2IWWVF2no2
„exF2ƒt—te2felF2 of2
petFAF2
€rogr—m2viol—tions2r—nge2from2“very2inno™uous”2to24very2import—ntF”2
ehg’s2 re™ord2 keeping2 viol—tionsD2 together2 with2 the2 prim—2f—™ie2 eviden™e2
presented2 ˜y2 rrƒgEysq2of2ehg’s2fr—ud2 —nd2 willful2 misrepresent—tionsD2
when2 —n—lyzed2 ™onsistently2 with2 „ex—s2 l—w2 —nd2 wedi™—id2 poli™yD2 justify2
m—int—ining2the2p—yment2holdF2
@„he2ƒyer2evts’2 proposed2pol‘2 xoF2 ƒU2st—tedX2 ehg s2viol—tion2 is2 —2te™hni™—l2
‘2
viol—tion2 —nd2˜—sed2upon2 this2 re™ord2does2 not2 rise2 to2 —2 level2 of2su˜st—ntive2
™on™ernFA2
‚e—son2for2gh—ngeX2
€roposed2polc2 xoF2SU2—ddresses2 —2mixed2question2of2f—™t2 —nd2l—wD2 —nd2is2 —2soE2
™—lled2“legisl—tive2findingF42 „hereforeD2the2ixe™utive2gommissioner2h—s2™omplete2
dis™retion2to2modify2itF2 „exF2 hep’t2loG4vi™ensing282‚egul—tion2†F2 „hompsonD2 HIQ2
‡v2QUWIRVTD2 —t2 BT2 @“en2—gen™y2enjoys2 ™omplete2 dis™retion2 in2 modifying2—n2
evt9s2findings2—nd2™on™lusions2when2those2findings2—nd2™on™lusions2refle™t2—2l—™k2
of2 underst—nding2 or2 mis—ppli™—tion2 of2 the2 existing2 l—wsD2 rulesD2 or2 poli™iesF”2
@quoting2ƒmith2vF2 wontem—yorD2PHHQ2 ‡v2 PIRHISWID2—t2BPTEPU2@emph—sis2—dd™dAAY2
„exF2qov’t2gode2§2P@AHIFHSV@™A@lAF2
€roposed2pop2xoF2SU2is2 erroneous2˜e™—use2it2 inis—pplies2„ex—s2l—w2—nd2wedi™—id2
poli™yD2 in™luding2to2 the2extent2this2 finding2rests2on2the2 f—lse2premise2th—t2ehg’s
QR
001777
re™ord2keeping2viol—tions2—re2the2only2—™tion—˜le2viol—tions2found2˜y2the2snspe™tor2
qener—lF2 „he2ƒyer2evts2—ppe—r2to2 re—son2th—t2 G’hg’s2progr—m2viol—tionsD2 ˜y2
themselvesF2 do2 not2justify2 ™ontinu—tion2 of2thep—yment2holdF2 „he2underlying2
premiseD2 in2 turnD2 is2 ˜—sed2the2 ƒyesEs2 evts2mis—ppli™—tion2 of2„ex—s2wedi™—id2
poli™y2reg—rding2 e™topi™2 eruptionF2 „his2 finding2is2 —lso2 erroneous2 ˜e™—use2 it2 is2
within2the2 sound2dis™retion2 of2the2 ixe™utive2 gommissionerD2—nd2not2the2 ƒyess2
evtsD2to2determine2whether2or2not2ehg92 s2re™ord2keeping2viol—tions2—re2™—use2for2
™on™emF2
„he2snspe™tor2 qener—l2˜—sed2 his2 p—yment2 holdD2 in2 p—nD2 on2 ehg’s2f—ilure2 to2
provide2re™ords2pursu—nt2to2 the2 snspe™tor2qener—l’s2requestF2 sn2some2™—sesD2ehg2
h—d2these2re™ordsD2—nd2entered2them2into2eviden™e2in2this2e—se2over2—2ye—r2qfler2the2
snspe™tor2 qener—l2 requested2 themF2 ehg’s2 f—ilure2 to2 provide2 these2 re™ords2
immedi—tely2 is2 —2 progr—m2 viol—tion2 —nd2m—y2result2 in2 —2 p—yment2holdF2 s2 „exF2
edminF2gode2§2 QUIFlTlU@PA@G’AY2 ‚EsR2—t2 sEV2 @“p—ilure2 to2 supply2the2requested2
do™uments2 —nd2 other2 itemsF2 within2 the2 time2 fr—me2 spe™ifiedD2 m—y2result2 in —2
p—yment2hold2 or2ex™lusion2from2wedi™—idf‘AF2
F2 F2 F2
€roposed2pop2xoF2 SU2is2 erroneous2 in2 ™h—r—™terizing2these2progr—m2viol—tions2 —s2
4te™hni™—l2viol—tion‘s“”2th—t2—re2not2“of2su˜st—ntive2™on™emD”2p—rti™ul—rly2in2light2
of2the2 f—™t2th—t2 the2 snspe™tor2qener—l2is2 o˜lig—ted2to2 investig—te2wedi™—id2fr—udD2
w—steD2 —nd2 —˜useD2 —ndD2 in2 the2 ™ourse2 of2 investig—tingD2 is2 entitled2 to2 request2
do™uments2 of2providersF2 ixF2 ‚EsR2 @PHHV2 „w€€wA2§2 IFPFQF2 siurthermoreD2 the2
snspe™tor2qener—l2is2 entitled2to2 ˜—se2p—yment2hold2determin—tions2on2the2re™ords2
th—t2wedi™—id2providers2provide2in2response2to2—2proper2request2on2the2p—rt2of2the2
snspe™tor2 qener—lF2 wedi™—id2 providers42 f—ilure2 to2 provide2 do™uments2 to2 the2
snspe™tor2 qener—l2 pursu—nt2 to2 —2 written2 request2 for2 them2 is2 —2 “su˜st—ntive2
™on™ernF”2 p—rti™ul—rly2 in2 ™—sesD2 like2this2 oneD2where2the2 provider2l—ter2—tt—™ks2the2
v—lidity2 of2the2 p—yment2hold2 ˜—sed2on2the2 existen™e2 of2do™uments2 it2 f—iled2 to2
provide2 to2 the2 snspe™tor2 qener—lF2 „he2 existen™e2 —nd2 provision2 of2do™uments2
ne™ess—ry2to2 fully2 do™ument2—nd2ev—lu—te2 the2 ne™essity2—nd2delivery2of2medi™—l2
servi™es2 is2 p—r—mount2to2the2integrity2of2the2wedi™—id2systemF2ƒee2€ier™e2vF2 „exF2
‚—™ing2gomm2UID2 PIP2 ƒF‡FQd2URSD2 USR2 @„exF2 eppF—eustin2PHHTD2 petF2 deniedA2
@—gen™y2detemiines2—ppropri—te2 pen—lty2to2 further2—gen™yG’s2 go—ls2 of2™ompli—n™e2
with2 st—te2 l—wA2 @™iting2 piremen9s2 82 €Hli™emen9s2 givil2 ƒervF2 gHmm9n2 vF2
frlnkmeyerD2TTP2ƒF‡FPd2WSQF2WST2@„exF2IFWVRAAY2 ƒee2—lso2 „exF2 ƒt—te2f—’2 of2hent—l2
F2
ix—m rs2 vF2 frownD2PVI2 ƒF‡FQd2TWPD2TWU2@„exF2 G’ppF—gorpus2ghristi2 PHHWD2petF2
92
deniedA2@—gen™yD2not2evsD2determines2—ppropri—te2s—n™tionAF2
„he2ƒyer2evts2—lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 p2op2PWF2 QIF2 —nd2QQD2 for2their2underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2 gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n
QS
001778
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2 l—w2 —nd2wedi™—id2poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2§2PHHI2FHSV@eA@PAF2
woreoverD2 the2 proposed2 finding2 relle™ts2 —2 fund—ment—l2 misunderst—nding2 —nd2
mis—ppli™—tion2ol’2„ex—s2l—w2—nd2wedi™—id2poli™y2˜y2the2ƒyer2evt2 sF2 en2—™™ur—te2
underst—nding2of2the2s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™y2is2 ™riti™—lly2
import—nt2to2the2out™ome2of2this2 disputeF2 „he2fund—ment—l2—lleg—tion2˜rought2˜y2
the2 snspe™tor2 qener—l2 is2 th—t2 ehg2h—s2 su˜mitted2 ™l—ims2 for2 €e2 —nd2 for2
reim˜ursement2th—t2—re2not2—uthorized2under2wedi™—id2poli™y2or2„ex—s2l—wF2 „hese2
—lleg—tions2™—nnot2˜e2properly2ev—lu—ted2if2the2f—™t2finder2does2not2underst—nd2the2
poli™yF2„hereforeD2there2is2 —2r—tion—l2™onne™tion2˜etween2the2™orre™t2—rti™ul—tion2of2
wedi™—id2poli™y2 —nd2the2modified2finding2of2f—™tD2 whi™h2—™™ur—tely2refle™ts2th—t2
poli™yF2ƒeeD2 eF2gFD2 rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2esso™F2 vF2 „giD2QWQ2
ƒF‡FQd2—t2 RRHERIY2ƒt—te2 vF2 wi—’Eƒouth2€—versD2 sn—D2 PRT2ƒF‡FQd2—t2 UPVY2vevy2vF2
„exF2ƒt—te2fdF2HfwedF2ix—m2’rsD2 WTT2ƒF‡FPd2—t2VITF2
gyxgv…ƒsyxƒ2yp2ve‡2
rrƒgEylq2h—s2jurisdi™tion2over2this2 ™—seF2 „exF2qov9t2gode2™hF2 SQ“Y2„exF2 rumF2
‚esF2gode2™hF2QPF2
ƒyer2h—s2jurisdi™tion2over2the2he—ring2pro™ess2—nd2the2prep—r—tion2—nd2issu—n™e2
of2—2propos—l2for2de™isionD2with2findings2of2f—™t2—nd2™on™lusions2of2l—wF2„exF2qov9t2
gode2™hF2PHHQF2
xoti™e2of2the2he—ring2w—s2properly2providedF2„exF2qov9t2gode2™hF2PHHIF2
„he2snspe™tor2qener—l’s2˜urden2to2 m—int—in2the2p—yment2hold2under2se™tion2
SQlFlHP@gA@PA2of2the2 qovernment2gode2or2se™tion2 QPFHPWl@™A2 of2the2 rum—n2
‚esour™es2godeD2is2 to2show2˜y2reli—˜le2or2prim—2f—™ie2eviden™e2th—t2ehg2h—s2
™ommitted2fr—ud2or2m—de2willful2misrepresent—tionsF2
@„he2 ƒyer2evts’2 proposed2gov2xoF2 R2 st—tedX2 rrƒgEysq2h—d2the2 ˜urden2of2
proofA2
‚e—son2for2gh—ngeX2
„he2ixe™utive2gommissioner2modifies2€roposed2gov2xoF2RF2 €roposed2gov2xoF R2
is2 erroneous2 ˜e™—use2 it2 is2 —2 misst—tement2 of2the2 l—wF2 ƒee2 „exF2 qov‘t2 gode §2
PH@AlF@ASV@eA@IAF2 „he2inspe™tor2 qener—l2 is2 required2˜y2l—w2to2 impose2 —2 p—yment2
hold24on2re™eipt2of2reli—˜le2eviden™e2th—t2the2™ir™umst—n™es2giving2rise2to2the2hold2
on2p—yment2involve2 fr—ud2or2willful2 misrepresent—tion2under2the2 st—te2 wedi™—id2
progr—m2 in2 —™™ord—n™e2 with2 RP2 gFpF‚F2 ƒe™tion2 RSSFPQF“2 „exF2 qov’t2 gode §2
SQlFlHP@gA@PAF2 eddition—llyF2 4‘t“he2 dep—rtment2sh—ll2 dis™ontinue2the2hold2unless2
the2dep—rtment2m—kes2—2prim—Giz™ie2showing2—t2the2he—ring2th—t2the2eviden™e2relied2
on2˜y2the2dep—rtment2in2imposing2the2hold2is2 relev—ntD2™redi˜le2—nd2m—teri—l2to2the2
issue2of2fr—ud2or2willful2 misrepresent—tionF“2 „exF2 rumF2‚esF2gode2§2 QPFHPWl@™A
QT
001779
@emph—sis2 —ddedAF2 fe™—use2 the2 ƒyer2 GE’vts’2 proposed2 ™on™lusion2 of2 l—w2
misst—ted2 the2 —ppli™—˜le2 l—wD2 the2 ixe™utive2 gommissioner2 h—s2 dis™retion2 to2
modify2 itF2 „hompsonD2 PHIQ2 ‡v2 QUWIRVTD2 —t2 BTY2 „exF2 qHv’t2 gode §2
PHHlFHSV@eA@lAF2
„he2ƒHGE’Fr2evs2 s2 —lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2p—rti™ul—rlyD2pop2PWD2 QID2 —nd2QQD2 for2 their2 underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2 gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2l—w2 —nd2i’Gledi™—id2 poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2§2PHHI2FHSV@eA@PAF2
woreoverD2the2 proposed2™on™lusion2refle™ts2 —2fund—ment—l2misunderst—nding2—nd2
mis—ppli™—tion2of2„ex—s2l—w2˜y2the2 ƒyer2ev“2sF2 „hereforeD2there2 is2 —2r—tion—l2
™onne™tion2˜etween2„ex—s2l—w2—nd2wedi™—id2poli™y2—nd2the2modified2™on™lusion2
of2l—wF2ƒeeD2eF2gFD2 rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2esso™F2 vF2 „giD2QWQ2
ƒF‡FQd2—t2 RRHERIY2ƒt—te2vF2 widEƒouth2€—versD2 sn™FD2 PRT2ƒF‡FQd2—t2 UPVY2vevy2vF2
„exF2ƒt—te2f—’2 ofwedF2ix—m2’rsD2 WTT2ƒF‡FPd2—t2VITF2
F2
S knowingly2m—ke2or2™—use2to2˜e2m—de2—2f—lse2st—tement2or2
lt2 is2 —n2unl—wful2—™t2to2
misrepresent—tion2 of2—2 m—teri—l2 f—™t2 to2 permit2 —2 person2to2 re™eive2 —2 ˜enefit2 or2
p—yment2under2the2wedi™—id2progr—m2th—t2is2 not2—uthorized2or2th—t2is2gre—ter2th—n2
the2 ˜enefit2 or2 p—yment2 th—t2 is2 —uthorizedF2 „exF2 rumF2 ‚esF2 gode2 §2 QTFHHP@lA2
@PHHQAF2
T „he2term2“knowingly”2me—ns2th—t2 the2 person2h—s2knowledge2of2the2 inform—tionD2
—™ts2with2™ons™ious2indifferen™e2to2the2truth2or2f—lsity2of2the2inform—tionD2or2—™ts2in2
re™kless2disreg—rd2of2the2truth2or2f—lsity2of2the2inform—tionF2€roof2of2the2person‘ s2
spe™ifi™2intent2to2™ommit2—n2unl—wful2—™t2under2§2 QTFHHP2is2 not2required2to2 show2
th—t2—2person2—™ted2“knowinglyF”2„exF2lsElumF2 ‚esF2gode2§2QTFHHII2@PHHQAF2
U2 “pr—ud”2is2—n2intention—l2de™eption2or2misrepresent—tion2m—de2˜y2—2person2with2the2
knowledge2th—t2 the2 de™eption2™ould2result2 in2 some2un—uthorized2˜enefit2to2 th—t2
person2 or2 some2 other2 personD2 in™luding2 —ny2 —™t2 th—t2 ™onstitutes2 fr—ud2 under2
—ppli™—˜le2feder—l2or2st—te2l—wF2„exF2qov4t2gode2§2SQIFIHI2I@IA2@PHI2IAF2
VF2 l9Il~lƒgEysq2 must2 impose2 —2 hold2 on2 p—yment2 of2 ™l—ims2 for2 reim˜ursement2
su˜mitted2 ˜y2 —2 provider2 on2re™eipt2 of2reli—˜le2 eviden™e2 th—t2 the2 ™ir™umst—n™es2
giving2rise2to2the2hold2on2p—yment2involve2fr—ud2or2willful2misrepresent—tion2under2
the2st—te2wedi™—id2progr—mF2„ex—s2qov’t2gode2§2SQ2lFlHP@gA@PA2@PHI2IAF2
WF2 ell2 wedi™—id2p—yments2to2—2provider2must2˜e2suspended2—fter2the2st—te2wedi™—id2
—gen™y2 determines2 th—t2 there2 is2 —2 ™redi˜le2 —lleg—tion2 of2 fr—ud2 for2 whi™h2 —n2
investig—tion2 is2 pendingD2 unless2 the2 —gen™y2 h—s2 good2 ™—use2 not2 to2 suspend2
p—yments2 @or2 to2 suspend2 p—yments2 only2 in2 p—itAF2 sf2 the2 st—te’s2 wedi™—id2 fr—ud2
™ontrol2 unit2 —™™epts2 —2 referr—l2 for2 investig—tion2 of2the2 providerD2 the2 p—yment
QU
001780
suspension2 m—y2 ˜e2 ™ontinued2 until2 su™h2 time2 —s2 the2 investig—tion2 —nd2
—sso™i—ted2enfor™ement2pro™eedings2—re2™ompletedF2
—ny2
RP2gFpF‚F2§2RSSFPQ2@PHI2lAF2
e2 “gredi˜le2 —lleg—tion2 of2fr—ud”2 m—y2˜e2 “—n2
—lleg—tionD2 whi™h2 h—s2 ˜een2
verified2˜y2the2ƒt—teD2 from2—ny2sour™e”2in™ludingD2
˜ut2not2limited2toD2 ‘fr—ud2
hotline2 ™ompl—intsD2 ™l—ims2 d—t—2 miningD2 —nd2
p—tterns2 identified2 through2
provider2 —uditsD2 —nd2 l—w2 enfor™ement2 investig—tionsF2
elleg—tions2 —re2
™onsidered2 ™redi˜le2 when2 they2 h—ve2 indi™i—2 of2
reli—˜ility2 —nd2 the2 ƒt—te2
wedi™—id2—gen™y2h—s2 reviewed2 —ll2 —lleg—tionsD2 f—™tsD2 —nd2
eviden™e2™—refully2
—nd2—™ts2judi™iously2on2—2™—se—˜yE™—se2˜—sisF”2RP2gFpF‚F2
§2RSSFPF2
@„he2ƒyer2evts92proposed2gov2x2 oF2 lH2st—tedX2 4gredi˜le2—lleg—tion2 42
“2
—n2—lleg—tionD2whi™h2h—s2˜een2verified2˜y2the2ƒt—teD2fi9onz2 offr—ud2 is
42
—ny2sour™eD2 in™ludingD2
for2ex—mpleD2fi9—zGd2hotline2 ™ompl—intsD2 ™l—ims2d—t—2
miningD2 —nd2provider2—uditsD2
elleg—tions2—re2™onsidered2™redi˜le2when2they2h—ve2
indi™i—2of2reli—˜ility2—nd2the2
ƒt—te2wedi™—id2—gen™y2h—s2reviewed2—ll2
—lleg—tionsD2f—™tsD2 —nd2eviden™e2™—rejillly2
—nd2—™ts2judi™iouslv2on2—2™—seE˜yE™—se2˜—sisF2RP2@FspF‚F2 RSSFP2
§2 @PHIIAF2”FA2
‚e—son2for2gh—ngeX2
„he2ixe™utive2gommissioner2modifies2€roposed2gov2
xoF2 IHF2 €roposed2gov2xoF2
IH2omits2words2—nd2phr—ses2from2the2 st—tuteD2
—ll2 essenti—l2 to2 the2me—ning2of2the2
st—tuteX2 ‘“p—tterns2 identified2 through‘2
provider2 —udits”Y2 the2 ƒyer2evts2 —lso2
deleted2the2phr—se2“—nd2l—w2enfor™ement2investig—tions”2
“is”2for2“m—y2˜e”2
—nd2su˜stituted2the2word2
—nd2“for2ex—mple42for2“˜ut2not2limited2toF”2
fe™—use2 €roposed2 gov2 xoF2 lH2 in™orre™tly2 st—tes2
the2 l—wD2 the2 ixe™utive2
gommissioner2h—s2™omplete2dis™retion2to2modify2gov2xoF2
IH2to2™orre™tly2st—te2the2
l—wD2—dd2the2essenti—l2phr—ses2—nd2‡ords2of2“p—tterns2
identified2through42—nd2“—nd2
l—w2enfor™ement2investig—tions”2 —nd2su˜stitute2 the2
‡ords2“™—n2˜e”2 for2“is”2 —nd2
“˜ut2not2limited2to”2for2“for2ex—mpleF”2
ƒee2„hompsonD2PHIQ2‡v2QUWIRVTD2—t2 BTY2
„exF2qov’t2 gode2§2PHHIFHSV@eA@lAF2
„he2ƒyer2evts2—lso2erred2to2the2extent2th—t2they2relied2
on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 polc‘2 PWD2 QID2 —nd2
QQD2 for2their2 underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2
poli™yF2 „he2ixe™utive2gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2
th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2
„ex—s2l—w2—nd2wedi™—id2poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2
§2PHHlFHSV@eA@PAF2
woreoverD2 ˜e™—use2 the2 proposed2 ™on™lusion2
refle™ts2 —2 fund—ment—l2
misunderst—nding2—nd2mis—ppli™—tion2of2l—w2 the2ƒyer2
˜y2 evtsD2there2is2—2r—tion—l2
™onne™tion2˜etween2„ex—s2l—w2—nd2wedi™—id2
poli™y2—nd2the2modified2™on™lusion2
of2l—wF2ƒeeD2eFgFD2rerit—ge2on2the2ƒ—n2q—˜riel2
romeowners2esso™F2 vF2 „giD2QWQ2
ƒF‡FQd2—t2 RRHERIY2ƒt—te2 vF2 widEƒouth2€—versD2 ln™FF2 PRT2
ƒF‡FQd2—t2 UPVY2 vevy2vF2
„exF2ƒt—te2fdF2 ofzlGledF2 ix—m rsD2WTT2
ƒF‡FPd2—t2VITF
92
QV
001781
‘vY»9X—X•FE
E F2
FF
’E2 ‚2 ••2
FFD‘FFFFDF•~••FF••F•FF2
••P•F E2 ••2 FF2
’~b2
••2 FE•2
•F~FuDt2
ll2
rrƒgEysq2
m—y2impose2
if2 there2
is2 —2
p—yment2hold2
reli—˜le2
misrepresent—tion2 eviden™e2 on2future2
th—t2 the2 ™l—ims2
—ssist—n™e2 reg—rding2 provider2
progr—mF2 —2 h—s2 su˜mitted2
lPF2 Fln2 „exF2 ™l—im2 tor2
™ommitted2 ˜y2—2provider2
—2 ƒyer2
he—ring2 on2
rumF2‚esF2
gode2§2 reim˜ursement2 fr—ud2 or2 vvillful2
showing2 —2 QPFHPWI2 under2 the2
th—t2the2
eviden™e2 p—yment2holdD2
@˜A2@PHHQAF2
™redi˜leF2 medi™—l2
—nd2
‚esF2gode2 m—teri—l2to2
relied2
the2
upon2in2 rrƒgEysq2must2
§2QPFHPWI@¢A2 issue2 imposing2
offr—ud2or2 the2
m—ke2—2
IQF2 prim—2f—™ie2
rrƒgEysq2 @PHHQAF2 willful2 p—yment2 hold2is2
or2willful2 should2 misrepresent—tionF2 relev—ntD2
m—int—in2the2 „exF2
SQIFIHP@gA2misrepresent—tionD2 p—yment2 rumF2
@PHIIAY2 —nd2 hold2
@PHHQAY2I2
@gAD2@sAD2
„exF2
RP2gp‚2
edminF2gode2 §2RSSFPQ2
progr—m2 —g—inst2
viol—tionsF2
ehg2
for2—lleged2
@uAD2@PA@eAD2 @PHIIAY2
„exF2 „exF2 fr—ud2
§§2 qov’t2
@„he2ƒyer2 @SATRAD2 QUIFIUHQ@˜A@QAD2 rumF2‚esF2 gode
G’v“s’2 @SA@@cA2
@PHHSAE2 —nd2@˜A@SAD2 gode2§2QPFHWI@™A2 §2
3sP@lllI@ssl’2
GGze2 proposed2 QUIFITI2
„exF2 qov2 p™gGmen32GtoG™t’2 golF2xoF2 lQ2 U@—A@I•A@eA~2
I2gHFG2 —g—I92 st—tedX2
gode2
§2 §2SQIFIHP@D¢y2
Izsf2
ehgfiAr2 rrƒgEysq2l—™ks2
QUIF2ITG2 QPD2HWI@IA2 @PHIIAY2RP2 —lleged2
U@``zA@IA@GIA~@gA2 @PHHQAY2 s2 gp‚2§2RSSF2fr—n™32or2mIlvrepreseIIG—3I92
—ntGzHrI92
to2 t•‘y2
‚e—son2f @PHHSAFA „exF2 PQ2@PHIIAY2 HnF2
GsdGninF2
or@lI—n e2 gode2 „exF2
‘2
„he2 g X
§§2 QU2‘FI2UHQ2
IIIIIIIF2
‚esF2
ixe™utive2
l2Q2is2 DG˜A@QAD2
erroneous2gommissioner2
D2
of2this2 ˜e™—use2it2 modifies2
™—seF2 mis—pplies2 €roposed2gov2
F2
„his2
mis—ppli™—tion2 ™on™lusion2 „ex—s2l—w2 xoF2 IQF2
of2e™topi™2 ot‘wedi™—id’2 rests2 on2 the2 —nd2 €roposed2
s2 wedi™—id2
ƒyer2evts’2 poli™y2to2the2 gov2xoF2
—pply2the2 eruptionF2 purtherD2 limited2orthodonti™2
proper2 this2 ˜enefit2—nd2misinterpret—tion2
f—™ts2
fe™—use2 evidenti—ry2 ™on™lusion2
gov2xoF2 ˜urden2in2 refle™ts2the2 their2 —nd2
interpret—tions2 IQ2 rests2 on2
this2™—seF2 ƒyer2 mis™onstru™tion2
evts’2
of2 f—ulty2 f—ilure2to2
dis™retion2
to2 wedi™—id2
™orre™t2itF2 poli™y2the2 —ppli™—tions2 of2
PHHIFHSV@eA@lAF2 „GlolnpsonD2 I9Eixe™utive2 l—w2—s2
PHIQ2 ‡v2 ‡ell2 —s2
determines2 purtherD2 the2 gommissioner2 erroneous2
the2 ixe™utive2 QUWIRVTD2—t2
‘f—™ing2 —ppropri—te2 enjoys2
gomm nD2 ’2
PIP2 s—n™tion2 gommissionerD2
BTY2
„exF2 qov’t2 ™omplete2
@—gen™y2 ƒF2‡FQd2
if‘2
the2l—w2 —nd2 gode §2
determines2 h—s2˜een2 not2the2
with2st—te2
l—w2@™iting2—ppropri—te2
URSD2 USR2
@„exF2 viol—tedF2 ƒyer2
ƒee2€ier™e2 evtsD2
TTP2ƒF2 pen—lty2to2 eppF’eustin2 vF2 „2
‡FPd2WSQD2 pireGvzeGzlv2
82€HGi™enmzlv2 further2
—gen™y’2s2 PHHTF2petF2 deniedA2
exF2
frownD2 PVI2 WST2@„exF2
go—ls2 of2
@—gen™yF2not2 ‡FQd2 TWPD2
ƒF2 IWVRAAY2see2 givil2ƒeGEvF2
TWU2
evsD2determines2 @„exF2
—lso2 „exF2
ƒG—te2id2
gomm2 WP2 vF2
™ompli—n™e2
„he2 eppF’gorpus2 frinkmeyerD2
heni—l2
ƒyerevts2
—lso2erred2
—ppropri—te2 ofhenr—G2
ghristi2 ix—Giz’2
s—n™tionAF2 PHHWF2 I~Fs92
vF2
de™isionD2 to2the2 petF2
s™ope2—nd2 p—rti™ul—rlyD2 extent2 deniedA2
pop2PWF2 they2relied2 th—t2
limit—tions2
™lis—pproves2
of2these2 of2„ex—s2 QID2 —nd2 on2the2
wedi™—id2 QQD2 for2 G~GorGirigen2
their2
underst—nding2p—miGy2
findingsD2
—nd2 poli™yF2
„he2
expressly2 ixe™utive2 of2the2
™on™ludes2
th—t2they2 gommissioner2
QW were2˜—sed2
on2—n
001782
s
w2
ll2
†2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2 l—w2
—nd2wedi™—id2poli™yD2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2 PHHI2
§2 FHSV@eA@PAF2
woreoverD2the2proposed2™on™lusion2refle™ts2 —2fund—ment—l2
misunderst—nding2—nd2
mis—ppli™—tion2of2„ex—s2l—w2˜y2the2 ƒyer2evtsF2„hereforeD2
there2 is2 —2r—tion—l2
™onne™tion2˜etween2„ex—s2l—w2—nd2wedi™—id2poli™y2—nd2the2
modified2™on™lusion2
of2l—wF2ƒeeD2eF2gFD2rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2
esso™F2 vF2 „giD2QWQ2
ƒF‡FQd2—t2 RRHERIY2ƒt—te2 vF2 widEƒouth2€—versF2 sn™D2 PRT2ƒF‡FQd2
—t2 UPVY2 vevy2vF2
„exF2ƒt—te2f—’2 HfwedF2ix—m2’rsD2 WTT2ƒF‡FPd2—t2V2lTF2
F2
„he2 „ex—s2 qovernment2 gode2 m—nd—tes2 —2 p—yment2 hold2 when2
reli—˜le2
eviden™e2h—s2˜een2presented2of2fr—ud2or2willful2misrepresent—tionF2
„exF2qHv’t2
gode2§2SQlFlHP@gA@PAF2„he2ixe™utive2gommissioner2sh—ll2dis™ontinue2the2
hold2
unless2 the2dep—rtment2m—kes2—2prim—2f—™ie2showing2
—t2 the2 he—ring2th—t2 the2
eviden™e2 relied2 on2 ˜y2 the2 dep—rtment2 in2 imposing2 the2
hold2 is2 relev—ntD2
™redi˜le2—nd2m—teri—l2to2 the2issue2of2fr—ud2or2willful2
misrepresent—tionF2„exF2
rumF2‚esF2gode2§2QPFHPWl@™AF2
@„he2 ƒyer2evts’2 proposed2 gov2xoF2 sR2 st—tedX2 e2
p—yment2hold2should2˜e2
re—son—˜ly2rel—ted2to2the2nz—gnitmle2frlze2viol—tionFA2
‚e—son2for2gh—ngeX2
„he2ixe™utive2gommissioner2modifies2€roposed2gov2xoF2 lRF2
€roposed2gov2xoF2
IR2 is2 erroneous2 ˜e™—use2 it2 misst—tes2 the2 l—wF2
ƒee2 „exF2 qov’t2 gode §2
PHHlFHSV@eA@lAF2 „he2„ex—s2 qovemment2gode2m—nd—tes2 —2
p—yment2hold2 when2
reli—˜le2eviden™e2w—s2˜een2presented2of2fr—ud2or2
willful2 misrepresent—tionF2 „exF2
qov’t2gode2§2SQlFl@AP@gA@PAF2eddition—llyD2“l9t“he2
dep—rtment2sh—ll2dis™ontinue2 the2
hold2unless2the2 dep—rtment2m—kes2—2prim—f—™ie2showing2
—t2 the2 he—ring2th—t2 the2
eviden™e2relied2on2˜y2the2dep—rtment2in2imposing2the2hold2is2
relev—ntD2™redi˜le2—nd2
m—teri—l2to2the2issue2of2fr—ud2or2willful2misrepresent—tionF42
„exF2rumF2‚esF2gode2
§2QPFHPWI@™A2@emph—sis2—ddedAF2
fe™—use2the2 ƒyer2evts’2 proposed2™on™lusion2of2l—w2misst—ted2
the2 —ppli™—˜le2
l—wD2the2rrƒgEevt2h—d2™omplete2dis™retion2to2
modify2itF2 „hompsonD2PHIQ2‡v2
QUWIRVTD2—t2BTY2„exF2qov‘t2gode2§2PHHlFySV@eA@lAF2
„he2ƒyer2evts2—lso2erred2to2the2extent2th—t2they2relied2on2the2
r—rliGzgen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 pop2PWD2QID2 —nd2QQD2 for2their2
underst—nding2 of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2
ixe™utive2 gommissioner2
dis—pproves2of2these2findingsD2—nd2expressly2™on™ludes2th—t2
they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2 l—w2—nd2
wedi™—id2poli™yF2 —nd2
thereforeD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2
§2PHHlFHSV@eA@PAF2
woreoverD2the2 proposed2™on™lusion2refle™ts2—2fund—ment—l2
misunderst—nding2—nd2
mis—ppli™—tion2of2„ex—s2l—w2˜y2the2 ƒyesEE‘2 evtsF2 „hereforeD2
there2 is2 —2 r—tion—l2
™onne™tion2˜etween2„ex—s2l—w2—nd2wedi™—id2poli™y2—nd2the2
modified2™on™lusion
RH
001783
of2l—wF2ƒeeD2eF2gFD2 rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2esso™F2 vF2 „giD2QWQ2
ƒF‡FQd2—t2 RRHERIY2ƒt—te2 vF2 widEƒouth2€—versD2 s92n™FD2 PRT2ƒF‡FQd2—t2 UPVY2 vevy2vF2
wedF2ix—m2’rsD2 WTT2ƒF‡FPd2—t2VITF2
„exF2ƒt—te2f—’2 of2
F2
IX2 „he2prim—2p—™ie2eviden™e2est—˜lished2th—t2ehg2™ommitted2progr—m2viol—tions2˜y2
f—iling2 to2 m—int—in2 ™ert—in2 p—tient2 re™ords2 for2 the2 required2 five2 ye—rsF2 l2 „exF2
edminF2gode2§§2QUlFIUHQ@˜A@SAD@TAY2QUlFlTlU@PA@G’AD2@SA@G’A2—nd2@qA2@PHHSAF2
IT2 ehg’s2f—ilure2to2 immedi—tely2provide2ssrƒgEysq2with2the2do™uments2—nd2
other2items2requested2in2writingD2—long2with2the2extensive2—nd2overwhelming2
p—ttern2of2willful2misrepresent—tions2or2fr—ud2in2ehg’s2rvh2s™oresheetsD2—nd2
ehg’s2˜illing2 for2 nonEreim˜urs—˜le2servi™esD2 should2 result2 in2 —2 ™ontinuing2
p—yment2holdF2„exF2qov’t2gode2§2SQIFIHP@gA2@PHIIAY2„exF2rumF2‚esF2gode §2
QPFHPWI@™AY2 I2„exF2gode2§2QUIFITIU@PA@eA2@PHHSAY2PHHV2 „w€€w2
—t2IFPFQF2
@„he2ƒyer2evts’2proposed2gov2xHF2 IT2st—tedX2 „hese2te™hni™—l2viol—tions2 —re2
very2 limited2 in2 num˜er2—nd2—re2 innH™uHztFs9D92 thereforeD2 they2 do2 not2 w—rr—nt —2
p—yment2hold2in2this2™—seFA2
‚e—son2for2gh—ngeX2
„he2ixe™utive2gommissioner2modifies2€roposed2gov2xoF2ITF2 €roposed2gov2xoF2
IT2 is2 erroneous2 ˜e™—use2 @IA2 f—ilure2 to2 provide2 re™ords2 to2 rrƒgEysq2is2 —lso —2
progr—m2viol—tionY2 —nd2@PA2 f—ilure2to2 provide2re™ords2 to2 rrƒgEysq2is2 neither —2
te™hni™—l2 viol—tion2 nor2inno™uousD2 —s2 rrƒgEysq2de™ided2to2 impose2—2p—yment2
hold2on2ehg2˜—sed2on2the2p—tient2re™ords2it2 provided2in2response2to2 ‘srƒgEysq‘ s2
written2requestF2—nd2˜—sed2on2the2f—™t2th—t2ehg2f—iled2to2provide2™ert—in2re™ords2—t2
th—t2timeF2
fe™—use2 gyv2xoF2 lT2 rests2 on2 f—ulty2 —ppli™—tions2 of2l—w2 —s2 well—s2erroneous2
interpret—tions2 of2wedi™—id2poli™y2the2 ixe™utive2gommissioner2enjoys2™omplete2
dis™retion2to2™orre™t2itF2 „hompsonD2PHIQ2‡v2QUWIRVTD2—t2 BTY2„exF2qov’t2gode §2
PHHlFHSV@eA@lAF2 purtherF2 the2ixe™utive2gommissionerD2—nd2not2the2 ƒyer2evtsD2
determines2the2—ppropri—te2s—n™tion2if2the2l—w2h—s2˜een2viol—tedF2ƒee2€ier™e2vF2 „exF2
‚—™ing2gomGn9nD2 PIP2 ƒF‡FQd2URSD2 USR2 @„exF2 eppF—eustin2PHHTD2 petF2 deniedA2
@—gen™y2determines2 —ppropri—te2 pen—lty2to2 further2—gen™y’s2go—ls2 of2™ompli—n™e2
with2st—te2l—w2@™iting2p2 ireGnen9s282€oli™emen29s2 givil2ƒervF2 gomm2
9n2 vF2 frirtkmeyerD2
TTP2ƒF‡FPd2WSQD2WST2@„exFlWVRAAY2see2—lso2 „exF2 ƒt—te2fdF2 of2hent—l2ix—m’rs2vF2
frownD2 PVI2 ƒF‡FQd2 TWPD2 TWU2 @„™xF2 eppF—gorpus2ghristi2 PHHWF2 petF2 deniedA2
@—gen™yF2not2evtF2determines2—ppropri—te2s—n™tionAF2
„he2ƒyesEs2evts2—lso2erred2to2the2extent2th—t2they2relied2on2the2r—rlingen2p—mily2
hent—l2de™isionD2 p—rti™ul—rlyD2 pop2PWF2 QID2 —nd2QQD2 for2 their2 underst—nding2of2the2
s™ope2—nd2limit—tions2 of2„ex—s2wedi™—id2poli™yF2 „he2ixe™utive2 gommissioner2
dis—pprov™s2of2these2findingsD2—nd2expressly2™on™ludes2th—t2they2were2˜—sed2on2—n2
in™orre™t2 interpret—tion2 —nd2—ppli™—tion2 of2„ex—s2 l—w2—nd2wedi™—id2poli™yD2 —nd2
th™r™toreD2™—nnot2˜e2relied2onF2 „exF2qov’t2gode2§2 PHHI2FHSV@eA@PAF
R“
001784
misinterpret—tion2—nd2
woreoverD2 the2proposed2™on™lusion2refle™ts2 —2fund—ment—l2
mis—ppli™—tion2of2„ex—s2l—w2˜y2the2 ƒqer2evtsF2„hereforeD2
there2 is2 —2r—tion—l2
modified2 ™on™lusion2
™onne™tion2˜etween2„ex—s2l—w2—nd2wedi™—id2poli™y2—nd2the2
esso™F2vF2 „giF2QWQ2
of2l—wF2ƒeeD2eF2gFD2 rerit—ge2on2the2ƒ—n2q—˜riel2romeowners2
vevy2vF2
ƒF‡FQd2—t2 RRHERIY2ƒt—te2 vF2 widEƒouth2€—versD2 sn™FD2 PRT2ƒF‡FQd2—t2 UPVY2
„exF2ƒt—re2fdF2HfwedF2ix—m’rsD2WTT2ƒF‡FPd2—t2VITF2
st2 is2 further2 y‚hi‚ih2th—t2the2 IHH72p—yment2hold2instituted2on2epril2RD2 PHIP2
sh—ll2rem—in2in2pl—™e2until2further2order2of2the2ixe™utive2
gommissionerF2
ƒigned2this2jI•E2•2d—y2of2 I2
lfll2 ‘e2 on2
U2
DPHl•F2
I’2 •‘ ’
D2
ˆ2•r~R2‘wt2
†2 •2
v’F~’FF~BEis2
uyle2vF2t—n‘ekD@wFhDF9b2
ixe™utive2gommissioner
RP
001785
Append¡x B
lexas I Medicaid.gov Page 1 ofl
Learn about yg!Lhgq!!h!3Ig_9pl!!9!9
lhtto://www.healthca¡e.qovl
Medicaid,q*
Keeping Ameríca Healthy (/index.html)
Return to previous paqe
lome (/index.html) ¡ ) BY State
Texas
(/medica id-ch ip-oroqram-information/bv-state/bv-state. html)
State of Texas Website
(http:i/www. h hsc. state. tx. u s/)
Med icaid-Marketplace Overview
The Federally-facilitated Marketplace (FFM) is offering health coverage in Texas in 2015. The FFM will make assessments of Medicaid/CHIP
eligibility and then transfer the applicant's account to the state agency for a final eligibility determination. Texas has not expanded Medicaid
coverage to low-income adults.
Medicaid and CHIP Eligibility Levels
To view the
income-and-medicaid-chip.pdfl -based eligibility levels, expressed as a percentage of the federal poverty level (FPL) and by monthly dollar
amount and family size for Medicaid and cHlP, visit the
for more information.
State Medicaid Expansion Ghildren - Medicaid Separate CHIP Pregnant Women Parents3 Other Adults
Ages 0-11 Ages 1-52 Ages 6-182 Medicaid CHIP
Texas N 198% 144% 133% 201% 198o/o N/A 15% 0%
1. These el¡g¡b¡l¡ty standards include CHIP-funded Medicaid expans¡ons.
2 Children in separate CH\P programs are typically charged premiums Th¡s table does not include notations of states that have elected to provide CHIP coverage
from conception lo bit1h,
3 /n slafes that use dollar amounts rather than percentages of the federal poverty level (FPL) for 2013 to detemine eligibility for parents, we convefted those
amounts to a percent of lhe FPL and selected the highest percentage to reflecl eligib¡lity level for the group ln additíon, ¡n states that are adopting the Medicaid
expansion, we have indicaled the upper ¡ncome timit for parents to also be 133% of the FPL, s¡nce parents can be eligible for coverage under the new adult group.
The actuat dottar standards that states w,// use to determine eligibility are quoted in the monthly ¡ncome tables
Monthly Medicaid and CHIP Enrollment Data
Each month, CMS releases state-reported data on State Medicaid and CHIP program Enrollment. The enrollment data for each month is a point.in-
time count of total Medicaid and CHIP enrollment on the last day of the month, and is not solely a count of those newly enrolled during the reporting
period. Below,thisdataiscomparedtoaverageenrollmentfromJuly-September20l3,theperiodbeforetheinitial openenrollmentperiodofthe
Health lnsurance Marketplaces. Additional information and enrollment data is available on the Medicaid and CHIP Application, Eliqibility
State State Medica¡d & CHIP Enrollment National
Total Medica¡d & CHIP Comparison of February Total Medicaid & CHIP Gomparison of February 2015
Enrollment (February 2015 data to July-September Enrollment, all States data to July-September 2013
2015) (Preliminary) 20'l 3 Average Enrollment (February 2015) Average Enrollment
Net Change % Change
(Preliminary) Net Change % Change
Texas 4,655,609 214,004 4 82% 70,5'15,716 11 ,718,178 20 28%
Medicaid and CHIP Applications
The Affordable Care Act established a streamlined enrollment process through which individuals can gain access to affordable insurance coverage
for which they are eligible. The law directed the Secretary of Health and Human Services (HHS) to develop a model application that will be used to
. States have the option to adopt the
Secretary of HHS's model application form for affordable insurance programs or to adopt an alternative application that meets federal requirements
rttp://www.medicaid.gov/Medicaid-CHlP-Program-lnformatiorVBy-State/texas.html 51281201:
lexas I Medicaid.gov Page2 of ':
ln response to , many states have adopted one
or more "targeted enrollment strategies" designed to facilitate enrollment and retain coverage for eligible individuals in Medicaid/CHlP. The states
that have adopted one or more targeted enrollment strategies are listed on the Targeted Enrollment Strateqies (/medicaid-chip-proqram-
page.
Medicaid and CHIP State Plan Amendments
The state Medicaid and CHIP plans spell out how each state has chosen to design its program within the broad requirements forfederal funding. As
always, states amend their Medicaid and CHIP state plans in order to inform CMS of programmatic and financing changes and to secure legal
authority for those changes. The Affordable Care Act included many new opportunities for states to augment and improve their Medicaid and CHIP
programs. As a result there has been a great deal of state plan amendment activity over the past several years in the areas of eligibility, benefits
design and financing, as well as new approaches to providing health homes, long{erm services and supports, and enrollment strategies like
hospital presumptive eligibility. See below for a state-specific list of approved Medicaid and CHIP SPAs.
Amendments. htm l?filterBv=Texas)
Demonstrations and Wa¡vers
Demonstration and waivers are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and
CHIP. The primary types of waivers and demonstration projects include section 1115 demonstrations, section 1915(b) managed care waivers, and
section 1 915(c) home and community-based services waivers. More information about waivers is available on the Waivers (/medicaid-chip-
oroqram-information/bv{opics/wa ivers/waivers. html) page.
filterBv=Texas)
Medicaid Delivery System
States have choices in their approach to delivery system design under the Medicaid and CHIP programs. States are increasingly moving to the use
of and olhqjnleffated-gele
in serving their
Medicaid beneficiaries. On average, more than 70 percent of the Medicaid population is enrolled in some form of managed care.
GHIP Program lnformation
was established in 1997 to provide new coverage opportunities for
children in families with incomes too high to qualify for Medicaid, but who cannot afford private coverage. Like Medicaid, CHIP is administered by
the states, but is jointly funded by the federal government and states. States had the opportunity to desiqn their CHIP proqrams
(/chip/downloads/chip-map.pdfl as an expansion of Medicaid, as a stand-alone program orthrough a combined approach.
Medicaid/CHIP Participation Rates
The participation rate is the percentage of eligible children enrolled in Medicaid and CHIP in the state. Data from 2013 show 88.3 percent of the
eligible children in the Unifed States are enrolled in Medicaid and CHIP programs. More information about the participation rate among children in
Texas is available on
State Participation
Texas 83.7%
Medicaid/G HIP Eli gi bi lity Verification Plans
Medicaid and CHIP agencies now rely primarily on information available through data sources (e.9., the Social Security'Administration, the
Departments of Homeland Security and Labor) rather than paper documentation from families for purposes of verifying eligibility for Medicaid and
CHIP.
Texas's Medicaid and CHIP Verification
MAGI Gonversion Plans
CMS provided states w¡th a template for completing their "MAGl Conversion Plans" that are designed to reflect the MAG|-based eligibility standards
that are used to determine Medicaid and CHIP eligibility. The MAG|-conversion process involved a translation oÍ pre-2014 net income eligibility
standards into MAGI-based eligibility standards. Moving to MAGI replaced income disregards with simpler, more universal income eligibility rules
that are generally aligned with the rules that are used to determine eligibility for the premium tax credits in the Marketplace. To complete the
transformation to MAGI, states needed to "convert" their nelincome based eligibility standards to MAG|-based standards.
. Texas's MAGI Conversion Plan is currently in progress
marketplace/downloads/tx-converted{hresholds-26ap1201 3. pdf)
rttp://www.medicaid.gov/Medicaid-CHIP-Program-lnformatiorVBy-State/texas.html 5128120t:
Append¡x G
Texas Medicaid
and CHIP
n Perspective
Tenth Edition
Texas Health and Human Services Commission
February 2015
Ghapter 1: Texas Med¡ca¡d
I n Perspective
What is Medicaid? What is Medicaid managed care? How is lexas
Medicaid changing?
What ls Medicai d?
Medicaid is a jointly funded state-federal health care program, established in Texas in
1967 and administered by the Health and Human Services Commission (HHSC). ln
order to participate in Medicaid, federal law requires states to cover certain population
groups (mandatory eligibility groups) and gives them the flexibility to cover other
population groups (optional eligibility groups). Each state chooses its own eligibility
criteria within federal minimum standards. States can apply to the Centers for Medicare
& Medicaid Services (CMS) for a waiver of federal law to expand health coverage
beyond these groups. Medicaid is an entitlement program, which means the federal
government does not, and a state cannot, limit the number of eligible people who can
enroll, and Medicaid must pay for any services covered under the program. ln July
2013, about one in seven Texans (3.7 million of the 26.4 million) relied on Medicaid for
health coverage or long-term services and supports.
Medicaid pays for acute health care (physician, inpatient, outpatient, pharmacy, lab, and
x-ray services), and long-term services and supports (home and community-based
services, nursing facility services, and services provided in lntermediate Care Facilities
for lndividuals with an lntellectual Disability or Related Conditions (lCFs/llD))for people
age 65 and older and those with disabilities. ln state fiscal year (SFY)2013, total
expenditures (i.e. state and federal) for Medicaid were estimated to represent26.2
percent (about $25.6 billion) of Texas' budget'. The federal share of the jointly financed
program is determined annually based on the average state þer capita income
compared to the U.S. average. The federal share is known as the federal medical
i
All funds, excluding disproportionate share hospital (DSH), uncompensated care (UC), and Delivery
System lmprovement Program (DSRIP). Sources: Texas Medicaid History Report, August 2014, and
Fiscal Size-Up(s)..
1-1
Append¡x D
TÐI{S MEDICATD
PnovIDER PROCEDURE S MNNUAL
Volumes
1&2
This nra¡rual is available for download at www.tnrhp.conr, and ìs also available on CD. There are n'ìany benefits to using the ele ctronic manual,
includirrg easy navìgation r¡rith booknrarks and hyperlinked cross-references, the abílìty to quickly search for speclfic terms or codes, and form
printing on demand.
The Texas Medicaid & Healthcare Partnership (TM H P) is the claims administrator for Texas Medicaid under contract with the Texas Health
and Human Services Commission.
TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL.2
4.2.23 Hospitalization and ASC/HASC
Dental services performed in an ASC, HASC, or a hospital (either as an inpatient or an outpatient) may
be benefits of THSteps based on the medical or behavioral justification provided, or if one of the
following conditions exist:
. The procedures cannot be performed in the dental office.
. The client is severely disabled.
To satis$r the preadmission history and physical examination requirements of the hospital, ASC, or
HASC, a THSteps medical checkup for dental rehabilitation or restoration may be performed by the
child's primary care provider. Physicians who are not enrolled as THSteps medical providers must
submit claims for the examination of a client before the procedure with the appropriate evaluation and
management procedure code from the following table:
Procedure Code Place of Service (POS)
99202 POS I (office)
99222 POS 3 (inpatient hospital)
99282 POS 5 (outpatient hospital)
Refer to: Subsection 5.3.l.6, "Exception-to-Periodicity Checkups" in this handbook.
Note: The dental provider must submit claims to TMHP using the ADA Dental Claim Form to be
considered for reimbursement through THSteps Dental Services.
The dental provider is responsible for obtaining prior authorization for the services performed under
general anesthesia. Hospitals, ASC's, and anesthesiologists must obtain the prior authorization number
from the dental provider.
Contact the individual HMO for precertification requirements related to the hospital procedure. If
services are precertified, the provider receives a precertification number effective for 90 days.
In those areas of the state with Medicaid managed care, the provider should contact the managed care
plan for specific requirements or limitations. It is the dental provider's responsibility to obtain precerti-
fication from the client's HMO or managed care plan for facility and general anesthesia services if
precertification is required.
To be reimbursed by the HMO, the provider must use the HMO's contracted facility and anesthesia
provider. These services are included in the capitation rates paid to HMOs, and the facility or anesthe-
siologist risk nonpayment from the HMO without such approval. Coordination of all specialty care is
the responsibility of the client's primary care provider. The primary care provider must be notified by
the dentist or the HMO of the planned services.
Dentists providing sedation or anesthesia services must have the appropriate current permit from the
TSBDE for the level of sedation or anesthesia provided.
The dental provider must be in compliance with the guidelines detailed in General Information.
Note: Post-treatment authorizøtion will not be approved for codes that require mandatory prior
authorization.
4.2.24 Orthodontic Services (THSteps)
Orthodontic services for cosmetic purposes only are not a benefit of Texas Medicaid. Orthodontic
services are limited to the treatment of children who are l2 years of age and older with severe handi-
capping malocclusion, children who are birth through 20 years of age with cleft palate, or other special
medically necessary circumstances as outlined in Benefits and Limitations, which follows.
cH-r 82
CPT ONLY, COPYRIGHT 20IOAMERICAN MEDICAL ASSOCIATION ALL RICHl'S RESERVED
CHILDRENS SERV]CES HANDBOOK
4.2,24.1 Benefits and Limitations
Orthodontic services include the following:
. Correction of severe handicapping malocclusion as measured on the Handicapping Labiolingual
Deviation (HLD) Index. A minimum score of 26 points is required for full banding approval (only
permanent dentition cases are considered).
Refer to: Subsection 4.2.26,"Handicapping Labio-lingual Deviation (HLD) Index" in this handbook.
Exception: Retained deciduous teeth and cleft palates with gross malocclusion that will benefitfrom
early treatment. Cleft paløte cases do not have to meet the HLD 26-point scoring
requirement. Howeyer, it is necessary to submít ø sufficient narrøtive or outline of the
proposed treatment plan when requesting authorization for orthodontic services on cleft
pølate cases.
. Crossbite therapy.
. Head injury involving severe traumatic deviation.
The following limitations apply for orthodontic serylces:
. Orthodontic services for cosmetic purposes only are not a benefit of Texas Medicaid or THSteps.
. Orthognathic surgery, to include extractions, required or provided in conjunction with the appli-
cation of braces must be completed while the client is Medicaid-eligible in order for reimbursement
to be considered.
. Except for procedure code D8660, all orthodontic procedures require prior authorization for
consideration of reimbursement.
. The THSteps client must be Medicaid THSteps-eligible when authorization is requested and the
orthodontic treatment plan is initiated. It is the provider's responsibility to verifr that the client has
a current Medicaid Identification Form (Form H3087) or Medicaid Eligibility Verification Form
(Forms H1027 andHl027-A-C); that the date of birth on the form indicates the client is 20 years of
age or younger; and that no limitations are indicated.
. Prior authorization is issued to the requesting provider only and is not transferable to another
provider. Ifthe client changes providers or ifthe provider ceases to be a Medicaid provider for any
reason, a new prior authorization must be requested by the new provider.
Refer to: Subsection 4.2.24.4, "Transfer of Orthodontic Services" in this handbook.
The following procedure codes, policies, and limitations are applied to the processing and payment of
orthodontic services under THSteps dental services:
. Procedure code D8660 is allowed when:
. The client is referred to a dental provider to determine whether orthodontic services are
indicated and to determine the appropriate time to initiate such services.
. The client is referred to a dental provider and elects to receive services from another orthodontic
provider for justifiable reasons.
. Repeat visits at different age levels are required to determine the appropriate time to initiate
orthodontic treatment.
. Ifprocedure code D8660 is submitted within six months of procedure code D8080, procedure code
D8080 will be reduced by the amount that was paid for procedure code D8660.
. Procedure code D8680 is payable for one retainer per arch, per lifetime, and each retainer may be
replaced once because ofloss or breakage (prior authorization is required).
cU-r 83
CPT ONLY . COPYRICHT 20IO AMERICAN MEDICAL ASSOCIATION AI,L RICI] TS RËSERVEI)
TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL,2
. Procedure code D8670 must be submitted only when an adjustment to the appliances is provided
and may not be submitted before the date on which the orthodontic adjustment was performed. The
number of visits for monthly adjustments to the appliances is restricted to the number that was
authorized in the treatment plan. However, the number of monthly visits may be amended with
appropriate documentation of medical necessity while the client is Medicaid eligible.
. Procedure code D8670 is paid only in conjunction with a history of braces (code D8080), unless
special circumstances exist.
. All orthodontic procedure codes and appliances are global fees.
. Separate fees for adjustments to retainers are Rot payable.
. The appropriate procedure code must be submitted for those appliances required as part of the
treatment of cleft palate cases.
Special orthodontic appliances may also be used with full banding and crossbite therapy with approval
by the TMHP Dental Director.
. Procedure codes D5951, D5952,D5953, D5954, D5955, D5958, D5959, and D5960 are to be used as
applicable with documentation of medical necessity. Otherwise, use the appropriate special
orthodontic appliance code.
. Full banding is allowed on permanent dentition only, and treatment should be accomplished in one
stage and is allowed once per lifetime.
Exception: Cases of mixed dentition when the treotment Plan íncludes extractions of remainingprimary
teeth or cleft palate.
. Crossbite therapy is allowed for primary, mixed, or Permanent dentition.
. Providers must not request crossbite correction (limited orthodontics) for a mixed dentition client
when there is a need for full banding in the adult teeth. Crossbite therapy is an inclusive charge for
treating the crossbite to completion, and additional reimbursement is not provided for adjustments
or maintenance.
. If a case is not approved, the dentist may file a claim for payment of the diagnostic workup for
procedure codes used that were necessary to request the prior authorization (procedure codes
D0330, D0340, D0350, and D0470). The dentist may receive payment under these procedure codes
for no more than two cases out of every ten cases denied. The dentist should determine if the client's
condition meets orthodontic benefit criteria before performing a diagnostic workup.
. Procedure codes D8080, D8050, and D8060, are limited to one per lifetime.
. Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are l2
years of age and older or clients who have exfoliated all primary dentition. Crossbite therapy
includes diagnostic cast services.
4.2.24.2 Completìon of Treatment Plan
If a client reaches 2l years of age or loses Medicaid eligibility before the authorized orthodontic
treatment is completed, reimbursement is provided to complete the orthodontic treatment that was
authorized and initiated while the client was 20 years of age or younger, eligible for Medicaid THSteps,
and completed within 36 months. Any orthodontic-related service requested in the prior authorization
request (e.g., extractions or surgeries) must be completed before the loss of client eligibility. Services
cannot be added or approved after Medicaid THSteps eligibility has expired.
Exception: Medicøid wíII not reimburse for øny orthodontic services during a period of time when a
THSteps client is incarcerated. During a period of incørceration, the facility is responsible for
any and all dentøl services, including orthodontic services.
clt-r84
(]P'I'oNLY , (:OPYRtCHT 20IO AMERICAN MEDICAL ASSOCIATION ALL RICII'I'S ITESI]RVEI)
CHILDRENS SERVICES HANDBOOK
4.2.24.3 Premature Removol of Applìonces
The overall fee for orthodontic treatment (D8080) includes the removal of orthodontic brackets and
treatment appliances. Procedure codeD7997 may be used only when the appliances were placed by a
different provider with an unaffiliated practice (not a partner or office-sharing arrangement) and one of
the following conditions exist:
. There is documentation of a lack of cooperation from the client.
. The client requests premature removal and a release of liability form has been signed by the parent,
guardian, or client ifhe is at least l8 years ofage.
Providers must keep a copy of the release of liability form on file and are responsible for this documen-
tation during a review process.
4.2.24.4 Tra n sfe r of Orth od o ntì c S erv ice s
Prior authorization that has been issued to a dental provider for orthodontic services is not transferable
to another dental provider. The new provider must submit to TMHP a new prior authorization request
to get approval to complete the orthodontic treatment that was initiated by the original provider.
To complete the treatment plan, the client must be eligible for Medicaid with a current client Medicaid
Identification Form (Form H3087) or Medicaid Eligibility Verification Form (Form H1027).
If the client does not return for the completion of services and there is documented failure to keep
appointments by the client, the dental provider who initiated the services may submit a claim for
reimbursement. The claim must be received by TMHP within the 95-day filing deadline from the last
DOS.
The following supporting documentation must accompany the new request for orthodontia services and
must include the DOS the orthodontic diagnostic tools were completed and include:
. All of the documentation as required for the original provider.
. The reason the client left the previous provider, if known.
. An explanation of the treatment status.
. A complete treatment plan addressing all procedures for which authorization is being requested
(such as the number of monthly adjustments or retainers required to complete the case).
. A full diagnostic workup (procedure code D8080) with an HLD Index. The score of 26 points will
be modified according to any progress achieved.
Exception: The prior authorization requests for clíents who initiate orthodontic services before becoming
eligible for Medicaid do not require models or the HLD score sheet, nor does the client have
to meet the HLD Index of 26 points. However, a complete plan of treatment is required.
Note: If Medicaid clients initiate orthodontic services outside of Medicaid because they do not score
26 points on the HLD, they øre not eligible to høve their orthodontic services transferred to or
reimbursed by Medicaid.
Providers who want to request prior authorization to complete orthodontic treatment that was initiated
by another provider must complete a THSteps Dental Mandatory Prior Authorization Request Form
and send it with the complete plan of treatment, and the appropriate documentation for orthodontic
services or crossbite therapy to the TMHP Dental Director at the following address:
Texas Medicaid & Healthcare Partnership
THSteps Dental Prior Authorization Unit
PO Box 202917
Austin, TX78720-2917
cH- I85
CPT ONLY - COPYRICHT 20IO AMERICAN MEDICAL ASSOCIATfON ALL RICHTS RESERVED
TEXAS MED]CAID PROVIDER PROCEDURES MANUAL: VOL.2
4,2.24. 5 Co m p reh e n sÍve O rth o dont¡ c Treatm e nt
Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are l2 years
of age and older or clients who have exfoliated all primary dentition. Crossbite therapy includes
diagnostic cast services.
National procedure codes do not allow for any work-in-progress or partial submission of a claim by
separating the three orthodontic components: diagnostic workup, orthodontic appliance (upper), or
orthodontic appliance (lower).
When submitting claims for comprehensive orthodontic treatment, procedure code D8080, three local
codes must be submitted as remarks codes along with procedure code D8080. Local codes (procedure
codes22009, Diagnostic workup approved; Z20ll, Orthodontic appliance, upper; orZ20l2,
Orthodontic appliance, lower) must be placed in the Remarks Code field on electronic claims or Block
35 on paper claims.
Note: If the remørks code and procedure code D8080 are not submitted, the claim will be denied.
Each remarks code pays the correct reimbursement rate which, when combined, totals the maximum
payment of $775. Procedure code D8080 must be submitted on three separate details, with the appro-
priate remarks code, even if the claim submission is for the workup and full banding. Submission of only
one detail for a total of 9775 will not be accepted.
Example l: A client is approved for full banding, but after the initial workup, the client discontinues
treatment. This provider would submit the national procedure code D8080 and place the local code
22009, Diagnostic workup approved, in the Remarks/comment field. The claim would pay $175.
Example 2: A client is approved for full banding. The provider continues treatment and places the
maxillary bands. The provider would submit the national procedure code D8080 and place the local
procedure code22009, Diagnostic workup approved, andZ20ll, Maxillary bands, in the
Remarks/comment field. The claim would pay $475.
All electronic claims for procedure code D8080 must have the appropriate remarks code associated with
the procedure code.
Providers must adhere to the following guidelines for electronic claim submission so TMHP can
accurately apply the correct remarks code to the appropriate claim detail.
A Diagnostic Procedure Code (DPC) remarks code must be submitted, only once, in the first three b¡es
of the NTE02 at the 2400loop.
Example 1: For a claim with one detail, submitted with procedure code D8080 and remarks code22009,
enter the information as follows: DPCZ2009. The total submitted would be $175.
Example 2l-For a claim with two details, where details one and two are procedure code D8080 and the
remarks codes are 22009 andZ20ll, enter the information as follows: DPCZ2009Z20ll. The total
submitted would be $475.
Example 3: Fora claim with three details, where all three details are submitted separatelywith procedure
code D8080, enter the remarks code based on the order of the claim detail as follows:
DPCZ2009Z20llZ20l2. The total submitted would be $775.
This method ensures accurate and appropriate payment for services rendered and addresses the need for
submission of a partial claim.
cll 186
CPT ONLY, COPYRICHT 20IO AMERICAN MEDICAL ASSOCIATION ALL RICHTS RESERVED
Appendix E
ï¡xns Mr0rcnr0 Pnovrorn PR0cEDURES MRHuRT: Vor. 1
Welcomez2Ol0 Texas Medicaid Provider Procedures Manual
This manual is a comprehensive guide for Texas Medicaid providers. It contains information about Texas Medicaid
benefits, policies, and procedures. It also includes information about Texas Health Steps (THSteps), the Children's
Services Program and managed care programs, including Primary Care Case Management (PCCM).
Texas Medicaid policy published in this manual was implemented on or before fanuary l, 2010. Policy updates effective
after fanuary 2,2010, are published bimonthly in the Texas Medicaid Bulletin.
All
Texas Medicaid policy updates, which are published bimonthly in the Texas Medicaid Bulletin, supplement this
manual and update the policy it contains.
This manual is also available on the TMHP website at www.tmhp.com.
New Format for 2010
This year's manual features a new format that makes it easier to access the information providers need. The following
outlines the new format:
Volume l: General lnformation
Volume I applies to all health-care providers who are enrolled in Texas Medicaid and provide services to Texas Medicaid
clients. The sections in Volume I include general information for enrolling in the program, receiving appropriate
reimbursement, and claim submissions and appeals for services rendered.
. Contents
. Introduction
. TMHP Telephone and Address Guide
. Section l. Provider Enrollment and Responsibilities
. Section 2. Texas Medicaid Reimbursement
. Section 3. TMHP Electronic Data Interchange (EDI)
. Section 4. Client Eligibility
. Section 5. Prior Authorization
. Section 6. Claims Filing
. Section 7. Appeals
. Section 8. Managed Care
. Appendix A: State and Federal Offices Communications Guide
. Appendix B: Vendor Drug Program
. Appendix C: HIV/AIDS
. Appendix D: Medical Transportation
. Appendix E: Acronym Dictionary
. Index (for Volume I and all handbooks)
I
CPTONLY, COPYRICHT2OO9AMERICAN MEDICALASSOCIATION ALL RICHTS RESERVED
CHILDRENS SERVICES H,{NDBOOK
5.3.23 Hospitalization and ASC/HASC
Dental services performed in an ASC, HASC, or a hospital (either as an inpatient or an outpatient) may
be benefits of THSteps based on the medical or behavioral justification provided, or if one of the
following conditions exist:
. The procedures cannot be performed in the dental office.
. The client is severely disabled.
To satisfr the preadmission history and physical examination requirements of the hospital, ASC, or
HASC, a THSteps medical checkup for dental rehabilitation or restoration may be performed by the
child's primary care provider. Physicians who are not enrolled as THSteps medical providers should bill
for the examination of a client before the procedure with the appropriate evaluation and management
procedure code from the following table:
Procedure Code Place of Service (POS)
99202 POS I (office)
99222 POS 3 (inpatient hospital)
99282 POS 5 (outpatient hospital)
Providers enrolled in THSteps Medical should refer to subsection 6.3.1.6, "Exception-to-Periodicity
Checkups" in this handbook.
Note: The dental provider should bill TMHP using the ADA Dental Claim Form to be considered
for reimbursement through THSteps Dental Services.
Contact the individual HMO for precertification requirements related to the hospital procedure. If
services are precertified, the provider receives a precertification number effective for 90 days.
In those areas of the state with Medicaid managed care, the provider should contact the managed care
plan for specific requirements or limitations. It is the dental provider's responsibility to obtain precerti-
fication from the client's HMO or managed care plan for facility and general anesthesia services if
precertification is required.
To be reimbursed by the HMO, the provider must use the HMO's contracted facility and anesthesia
provider. These services are included in the capitation rates paid to HMOs, and the facility or anesthe-
siologist risk nonpayment from the HMO without such approval. Coordination of all specialty care is
the responsibility of the client's primary care provider. The primary care provider must be notified by
the dentist or the HMO of the planned services.
Dentists providing sedation or anesthesia services must have the appropriate current permit from the
TSBDE for the level of sedation or anesthesia provided.
The dental provider must be in compliance with the guidelines detailed in General Information.
Note: Post-treatment authorization will not be approved for codes that require mandatory prior
authorization.
5.3.24 Orthodontic Services (THSteps)
Orthodontic services for cosmetic purposes only are not a benefit of Texas Medicaid. Orthodontic
services are limited to the treatment of children l2 years of age or older with severe handicapping maloc-
clusion, children birth through 20 years of age with cleft palate, or other special medically necessary
circumstances as outlined in Benefits and Limitations, which follows.
clt-l ól
CPT ONLY , (]OPYRICI IT 2OO9 AMERICAN MEDJCAL ÀSSOCIATION AI-L RIGHTS RESERVED
TEXAS MEDICA]D PROVIDER PROCEDURES MANUAL: VOL.2
5.3.24.1 BenefÍts and Limitations
Orthodontic services include the following:
. Correction of severe handicapping malocclusion as measured on the Handicapping Labiolingual
Deviation (HLD) Index. Refer to subsection 5.3.26,"How to Score the Handicapping Labio-lingual
Deviation (HLD) Index" in this handbook for information on how to score the HLD. A minimum
score of 26 points is required for full banding approval (only permanent dentition cases are
considered).
Erception: Retained deciduous teeth and cleft palates with gross malocclusion that will benefit from
eaily treøtment. Cleft palate cases do not have to meet the HLD 26-point scoring
requirement. However, it is necessary to submit a sfficient narrative and/or outline of the
proposed treatment plan when requesting authorizøtion for orthodontic services on cleft
Palate cases.
. Crossbite therapy.
. Head injury involving severe traumatic deviation.
The following limitations apply for orthodontic services:
. Orthodontic services for cosmetic purposes only are not a benefit of Texas Medicaid or THSteps.
. Orthognathic surgery, to include extractions, required or provided in conjunction with the appli-
cation of braces must be completed while the client is Medicaid-eligible in order for reimbursement
to be considered.
. Except for procedure code D8660, all orthodontic procedures require prior authorization for
consideration of reimbursement.
. The THSteps client must be Medicaid THSteps-eligible when authorization is requested and the
orthodontic treatment plan is initiated. It is the provider's responsibility to veri$ that the client has
a current Medicaid Identification Form (Form H3087) or Medicaid Eligibility Verification Form
(Forms H1027 andHl027-A-C); that the date of birth on the form indicates the client is 20 years of
age or younger; and that no limitations are indicated.
. Prior authorization is issued to the requesting provider only and is not transferable to another
provider. If the client changes providers or if the provider ceases to be a Medicaid provider for any
reason, a new prior authorization must be requested by the new provider.
Refer to: Subsection 5.3.24.4, "Transfer of Orthodontic Services" in this handbook.
The following procedure codes, policies, and limitations are applied to the processing and payment of
orthodontic services under THSteps dental services:
. Procedure code D8660 is allowed when:
. The client is referred to a dental provider to determine whether orthodontic services are
indicated and to determine the appropriate time to initiate such services.
. The client is referred to a dental provider and elects to receive services from another orthodontic
provider for justifiable reasons.
. Repeat visits at different age levels are required to determine the appropriate time to initiate
orthodontic treatment.
. If procedure code D8660 is billed within six months of procedure code D8080, procedure code
D8080 will be reduced by the amount that was paid for procedure code D8660.
. Procedure code D8680 is payable for one retaíner per arch, per lifetime, and each retainer may be
replaced once because ofloss or breakage (prior authorization is required).
cll- r64
CPT ONLY - COPYRICËIT 2OO9 AJ\4ERICAN MEDICAL ASSOCIATION ALL RIGT]'TS RESERVED
CHILDRENS SERVICES HANDBOOK
. Procedure code D8670 should be billed only when an adjustment to the appliances is provided and
may not be billed before the date on which the orthodontic adjustment was performed. The number
of visits for monthly adjustments to the appliances is restricted to the number that was authorized
in the treatment plan. However, the number of monthly visits may be amended with appropriate
documentation of medical necessity while the client is Medicaid eligible.
. Procedure code D8670 is paid only in conjunction with a history of braces (code D8080), unless
special circumstances exist.
. All orthodontic procedure codes and appliances are global fees.
. Separate fees for adjustments to retainers are not payable.
. The appropriate procedure code should be billed for those appliances required as part of the
treatment of cleft palate cases.
Special orthodontic appliances may also be used with full banding and crossbite therapy with approval
by the TMHP Dental Director.
. Procedure codes D5951, D5952, D5953, D5954,D5955, D5958, D5959, and D5960 are to be used as
applicable with documentation of medical necessity. Otherwise, use the appropriate special
orthodontic appliance code.
. Full banding is allowed on permanent dentition only, and treatment should be accomplished in one
stage and is allowed once per lifetime.
Exception: Cases of mixed dentition when the treatment plan includes extractions of remaining primøry
teeth or cleft paløte.
. Crossbite therapy is allowed for primary, mixed, or permanent dentition.
. Providers must not request crossbite correction (limited orthodontics) for a mixed dentition client
when there is a need for full banding in the adult teeth. Crossbite therapy is an inclusive charge for
treating the crossbite to completion, and additional reimbursement is not provided for adjustments
or maintenance,
. If a case is not approved, the dentist may file a claim for payment of the diagnostic workup for
procedure codes used that were necessary to request the prior authorization (procedure codes
D0330, D0340, D0350, and D0470). The dentist may receive payment under these procedure codes
for no more than two cases out of every ten cases denied. The dentist should determine if the client's
condition meets orthodontic benefit criteria before performing a diagnostic workup.
. Procedure codes D8080, D8050, and D8060, are limited to one per lifetime.
. Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are l2
years of age or older or clients who have exfoliated all primary dentition. Crossbite therapy includes
diagnostic cast services.
5.3.24.2 Completion of Treatment PIan
If a client reaches 2l years of age or loses Medicaid eligibility before the authorized orthodontic
treatment is completed, reimbursement is provided to complete the orthodontic treatment that was
authorized and initiated while the client was 20 years of age or younger, eligible for Medicaid THSteps,
and completed within 36 months. Any orthodontic-related service requested in the prior authorization
request (e.g., extractions or surgeries) must be completed before the loss of client eligibility. Services
cannot be added or approved after Medicaid THSteps eligibility has expired.
Exception: Medicaid will not reimburse for any orthodontic services during a period of time when a
THSteps client is incarcerated. During a period of incarceration, the facílity is responsible for
any and all dentøI services, includíng orthodontic seruices.
cH-165
CPT ONLY - COPYRICHT 2OO9 AMERICAN MEDICAL ASSOCIATION ALL RICHTS RESERVED
TEXAS MEDICA]D PROV]DER PROCEDURES MANUAL: VOL.2
5.3.24.3 Premature Removal of Appliances
The overall fee for orthodontic treatment (D8080) includes the removal of orthodontic brackets and
treatment appliances. Procedure codeD7997 may be used only when the appliances were placed by a
different provider with an unaffiliated practice (not a partner or office-sharing arrangement) and one of
the following conditions exist:
. There is documentation of a lack of cooperation from the client.
. The client requests premature removal and a release of liability form has been signed by the parent,
guardian, or client ifhe is at least l8 years ofage.
Providers must keep a copy of the release of liability form on file and are responsible for this documen-
tation during a review process.
5.3.24.4 Tronsfer of Orthodontìc Services
Prior authorization that has been issued to a dental provider for orthodontic services is not transferable
to another dental provider. The new provider must submit to TMHP a new prior authorization request
to get approval to complete the orthodontic treatment that was initiated by the original provider.
To complete the treatment plan, the client must be eligible for Medicaid with a current client Medicaid
Identification Form (Form H3087) or Medicaid EligibilityVerification Form (Form H1027).
If the client does not return for the completion of services and there is documented failure to keep
appointments by the client, the dental provider who initiated the services may submit a claim for
reimbursement. The claim must be received by TMHP within the 95-day filing deadline from the last
DOS.
The following supporting documentation must accompany the new request for orthodontia services and
must include the DOS the orthodontic diagnostic tools were completed and include:
. AII of the documentation as required for the original provider.
. The reason the client left the previous provider, if known.
. An explanation of the treatment status.
. A complete treatment plan addressing all procedures for which authorization is being requested
(such as the number of monthly adjustments or retainers required to complete the case).
. A full diagnostic workup (procedure code D8080) with an HLD Index. The score of 26 points will
be modified according to any progress achieved.
Exception: The prior authorization requests for clients who initiate orthodontic services before becoming
eligible for Medicaid do not require models or the HLD score sheet, nor does the client høve
to meet the HLD Index of 26 points. However, a complete plan of treatment is required.
Note: If Medicaid clients initiate orthodontic services outside of Medicaid because they do not score
26 points on the HLD, they are not eligible to have their orthodontic services transferred to or
reimbursed by Medicaid.
Providers who want to request prior authorization to complete orthodontic treatment that was initiated
by another provider must complete a THSteps Dental Mandatory Prior Authorization Request Form
and send it, the complete plan of treatment, and the appropriate documentation for orthodontic services
or crossbite therapy to the TMHP Dental Director at the following address:
Texas Medicaid & Healthcare Partnership
THSteps Dental Prior Authorization Unit
PO Box 202917
Austin, TX78720-2917
cu-166
CPT ONLY - COPYRIC}IT 2OO9 AMERICAN MEDICAL ASSOCIATION ALL RICHTS RESERVED
CHILDRENS SERVICES HANDBOOK
5,3,24.5 Comprehensìve Orthodontic Treatment
Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are l2 years
of age or older or clients who have exfoliated all primary dentition.
National procedure codes do not allow for any work-in-progress or partial billing by separating the three
orthodontic components: diagnostic workup, orthodontic appliance (upper), or orthodontic appliance
(lower).
When billing for comprehensive orthodontic treatment, procedure code D8080, three local codes must
be submitted as remarks codes along with procedure code D8080. Local codes (procedure codes22009,
Diagnostic workup approved; Z20ll, Orthodontic appliance, upper; or Z2Ol2, Orthodontic appliance,
lower) must be placed in the Remarks Code field on electronic claims or Block 35 on paper claims.
Note: lf the remarks code and procedure code D8080 are not submitted, the claim wiII be denied.
Each remarks code pays the correct reimbursement rate which, when combined, totals the maximum
payment of $775. Procedure code D8080 must be billed on three separate details, with the appropriate
remarks code, even if billing for the workup and full banding. Billing only one detail for a total of $775
will not be accepted.
Example l: A client is approved for full banding, but after the initial workup, the client discontinues
treatment. This provider would bill the national procedure code D8080 and place the local code 22009,
Diagnostic workup approved, in the Remarks/comment field. The claim would pay $175.
Example 2: A client is approved for full banding, The provider continues treatment and places the
maxillary bands. The provider would bill the national procedure code D8080 and place the local
procedure code 22009, Diagnostic workup approved, and Z2Oll , Maxillary bands, in the
Remarks/comment field. The claim would pay $475.
All electronic claims for procedure code D8080 must have the appropriate remarks code associated with
the procedure code.
Providers should adhere to the following guidelines for electronic claim submission so that TMHP can
accurately apply the correct remarks code to the appropriate claim detail.
A Diagnostic Procedure Code (DPC) remarks code must be submitted, only once, in the fìrst three b¡es
of the NTE02 at the 2400 loop.
Example l: For a claim with one detail, submitted with procedure code D8080 and remarks code22009,
enter the information as follows: DPCZ2009. The total billed would be $175.
Example 2: For a claim with two details, where details one and two are procedure code D8080 and the
remarks codes are 22009 andZ20l l, enter the information as follows: DPCZ2009Z20l l. The total billed
would be $475.
Example 3: For a claim with three details, where all three details are submitted separately with procedure
code D8080, enter the remarks code based on the order of the claim detail as follows:
DPCZ2009Z20||Z2Q|2. The total billed would be $775.
This method ensures accurate and appropriate payment for services rendered and addresses the need for
partial billing.
cÐ-167
CPT ONLY - (:OPYRICIIT 2OO9 AIVf IiIì,I(]AN ì\4EDICAL,ASSOC¡ATION ALL RI(;HTS RESERVED
TEXAS MEDICAID PIì.OVIDER PROCEDUIìES MANUAL: VOL 2
5.3,24,6 Orthodontic Procedure Codes and Fee Schedule
When submitting claims for orthodontic procedures, use the following procedure codes:
Procedure
Code Limitations Maximum Fee
Orthodontic Services
D0330*, When requested orthodontic cases are submitted for authorization $ 100.00
D0340*, and denied, two out of ten denials will be paid. These four
D0350*, and procedure codes, when billed together for denied cases, replace
D0470* local procedure code 22010.
D7280 A 1-20 $62.s0
D7997* Replaces 22016. Not payable to the dentist who placed the $s0.00
appliance. Includes removal of arch bar and premature removal of
braces. A l-20
D8050* Replaces Z2OIB and 8l l0D. Limited to one per lifetime. $340.00
D8060* Replaces 22018 and 8120D. Limited to one per lifetime. $340.00
D8080* Replaces 22009, Z20ll, and 22012. Limited to one per lifetime $77s.00
D8210* Refer to Subsection 5.3.25, "Special Orthodontic Appliances" below See separate
for associated remarks field code. table
D8220x Refer to Subsection 5.3.25, "Special Orthodontic Appliances" below See separate
for associated remarks field code. table
D8660* Replaces 22008. Denied when billed on the same DOS as D0120, $ 15.00
D0145, or D0150.
D8670* Replaces 22013. $68.10
D8680* Replaces 22014 and 22015; one retainer per arch per lifetime; may $ 100.00
be replaced once because ofloss or breakage (prior authorization is
required).
D8690* Bracket replacement. $20.00
D8691 Not considered medically necessary NC
D8692 Although procedure code D8692 is not a benefit of Texas Medicaid, NC
providers can use procedure code D8680 to bill for retainer(s).
Providers should include local code 22014 or 22015 on the claim
form to indicate upper or lower, as appropriate.
D8693 $s0 00
D8999 Manually
p riced
+ for
= Services payable to an FQHC a client encounter,
5.3.25 Special Orthodontic Appliances
All rernovable or fixed special orthodontic appliances rnust be prior authorized. The prior authorization
request musl" include both the national code and remarks code. However, prior authorization requests
may omit the DPC prefix to the eight-digit remarks code.
CI I I6{J
(lPlONl-\'(iOP\l{l(itll2Ur)9r\IIl,l{l(i,\NÀll,l)l(i?\l r\SSO(ll,\llON^llftl(ìlllSltf,Sl:R\/Ct)
Appendix F
Dear Manual User:
Welcome to the 2009 Texas Medicaid Provider Procedures Manual. To enhance usability, this manual
is available on a searchable CD-ROM and on the TMHP website at www.tmhp.com.
Note: Alt users who access www,tmhp.com are requìred to accept the American Medical Association
(AMA) End-user Agreement on the use of Current Procedural Terminology (CPT). For each computer that
accesses the TMHP website, the agreement must be accepted every 30 days from the last date on
which the agreement was accepted by the user. lf the end-user agreement is not accepted on a
particular computer every 30 days, no user will be able to enter the webs¡te from that computer, For
additional information about the AMA and CPT, refer to www.ama-assn.org/ama/pub/category
/3113.htm\.
A Ctaims Fiting Resources table is located at the end of each service section with page references to all
claim instructions, appendices, Medicaid forms, and claim form examples associated with the service.
This manual contains both the Primary Care Case Management (PCCM) and Texas Health Steps
(THSteps) manuals. PCCM information can befound primarily in Section 7, though relevant information
can be found in othersections. THSteps information is contained in Section 43 and throughoutthe
manual.
Texas Medicaid policy published ¡n this manual represents policy implemented on or before October 31,
2008. Policy updates effective after October 31, 2008, are published bimonthly in the lexas Medicaid
Bulletin.
The November/December 2OO8 Texas Medicaid Bulletin and all Texas Medicaid Bulletins through and
including the September/October 2OO9 Texas Medicaid Bulletin supplement the 2009 Texas Medicaid
Provider Procedures Manual and update the policy contained herein.
The Texas Medicaid Provider Procedures Manualserves as a comprehensive guide for Texas Medicaid
providers, and contains information aboutTexas Medicald benefits, policies, and procedures. The
manual also includes an overview of the State of Texas Medicaid Managed Care programs to include
the State of Texas Access Reform (STAR), STAR+PLUS, PCCM, and NorthSTAR. The information
regarding the State of Texas Medicaid Managed Care programs, including Section 7, is not an
exhaustive policies and procedures guide. Forspecific managed care information, contactthe individual
health plans participating in STAR, STAR+PLUS, and NorthSTAR. For PCCM, refer to the TMHP
Telephone and Address Guide included in this manual.
Provider Manual Overview
The 2008 Texas Medicaid Provider Procedures Manual is divided into three pafts, including:
Part l: Provider lnformation
The information in Part I is for all health-care providers who are enrolled in Texas Medicaid and provide
services to Texas Medicaid clients. ln Part l, providers find instructions for providing allowable services
and receiving appropriate reimbursementforservices. The followingsections are included in Part l:
. lntroduction
. TMHP Telephone and Address Guide
. Section 7. Provider Enrollment and Responsibilitles
. Section 2. Texas Medicaid Reimbursement
. Section 3. TMHP Electronic Data lnterchange (EDl)
. Section 4. Client Eligibility
. Section 5. Claims Flling
. Section 6. Appeals
. Section Z. Managed Care
Part ll: Texas Medicaid Services
Parl ll contains a section for each Texas lvledicaid service with information on health-care policy, proce-
dures, and claims filing peftaìning to each provìder type.
CP-f on y coDynght 2008 American il,4edical Assoclation All rrghts reserued
Provider Enrollment and Responsibilities
should allow longer than "at the time of the request" to Once a provider receives the request for medical records,
produce the records, the provider will be required to the provider must submit the information electronically or
produce all records completed, at the time of the in hard copy within 60calendar days. lt is important that
completion or at the end of each day of product¡on, as providers cooperate by submitting all requested documen-
directed by the requestor who will take custody of the tation in a timely manner because no response or
requested ¡tems. insufficient documentation will count against the state as
an error. This can ultimately negatively impact the amount
lf the provider places the required information in another
of federal funding received by Texas for Medicaid.
legal entity's records, such as a hospital, the provider is
responsible for obtaining a copy of these requested
records for use by the requesting state and federal
agencres.
t.4.4 Release of Gonfidential Information
lnformation about the diagnosis, evaluation, or treatment
These documents and claims must be retained for a
of a client with Texas Medicaid coverage by a person
minimum period of five years from the date of service or
licensed or certified to perform the diagnosis, evaluation,
until all aud¡t questions, appeal hearings, investigations,
or treatment of any medical, mental, or emotional
or court cases are resolved. Freestanding RHCs must
disorder, or drug abuse, is confidential informat¡on that
retain their records for a minimum of six years, and
the provider may disclose only to authorized people.
hospital-based RHCs must retain their records for a
Family planning information is sensitive, and confidenti-
minimum of ten years. These records must be made
ality must be ensured for all clients, especially minors.
available immediately at the time of the request to
employees, agents, or contractors of HHSC Office of Only the client may give written permission for release of
lnspector General (OlG), the Texas Attorney General's any pertinent information before client information can be
Medicaid Fraud Control Unit (MFCU) or Antitrust and Civil released, and confidentiality must be maintained in all
Medicaid Fraud Section, TMHP, DFPS, the Department of other respects. lf a client's medical records are requested
Aging and Disability Services (DADS), Department of State by a licensed Texas health-care provider or a physician
Health Services (DSHS), Department of Assistive and licensed by any state, territory, or insular possession of
Rehabilitative Services (DARS), U.S. Department of Health the United States or any State or province of Canada, for
and Human Services (HHS) representative, any state or purposes of emergency or acute medical care, a provider
federal agency authorized to conduct compliance, must furnish such records at no cost to the requesting
regulatory, or program ¡ntegrity functions on the provider, provider. This includes records received from another
person, or the services rendered by the provider or physician or healthcare provider involved in the care or
person, or any agent, contractor, or consultant of any treatment of the patient. lf the records are requested for
agency or division delineated above. ln addition, the purposes other than for emergency or acute medical care,
provider must meet all requirements of 1 TAC, Part 15, the provider may charge the requesting provider a
s371.1643(f). reasonable fee and retain the requested information until
payment is received.
The records must be available as requested by each of
these entities, during any investigation or study of the The client's signature is not required on the claim form for
appropriateness of the Medicaid claims submitted by the payment of a claim, but HHSC recommends the provider
provider. obtain written authorization from the client before
releasing confidential medical information. A release may
be obtained by having the client sign the indicated block
1".4.3.L Payment Error Rate Measurement on the claim form after the client has read the statement
(PERM) Process of release of information that is printed on the back of the
form. The client's authorization for release of such infor-
CMS assesses Texas Medicaid using the PERM process
mation is not requ¡red when the release is requested by
to measure improper payments in Texas Medicaid. and made to DADS, HHSC, DSHS, TMHP, DFPS, DARS,
Providers will be required to provide medical record
HHSC OlG, the Texas Attorney General's MFCU or
documentation to support the medical reviews that the
Antitrust and Civil Fraud Division, or HHS.
federal review contractor will conduct for Texas Medicaid
fee-for-service and PCCM Medicaid and State Children's
Health lnsurance Program (SCHIP) claims. L.4.5 Compliance w¡th Federal Legislation
Under the PERM process, if a claim is selected in a HHSC complies with HHS regulations that protect aga¡nst
sample for a service that a provider rendered to a discrimlnation. All contractors must agree to comply with
Medicaid client, the provider will be contacted to submit a the following:
copy of the medical records that support the medical
review of the claim. All providers should check the TMHP
. Title Vl of the Civil Rights Act of 1964 (Public Law
system to ensure their current telephone number and 88-352), Section 504 of the Rehabilitation Act of 1 97 3
addresses are correct in the system. lf the information is (Public Law 93-!t2), The Americans with Disabilities Act
incorrect or incomplete, providers must request a change of 1990 (Public Law 101-336), Title 40, Chapter 73, of
immediately to ensure the PERM medical record request the TAC, all amendments to each, and all requirements
can be delivered. Client authorization for release of this imposed by the regulations issued pursuant to these
information is not required. acts. The laws provide in pari that no persons in the
CPT only copyright 2008 Ameícan ¡/edical Association. All rights reseryed 1_-L3
Section 1
U.S. shall, on the grounds of race, color, nationalorigin, fully compliant with all three categories of the tamper-
age, sex, disability, political beliefs, or religion, be resistant regulations, provided they contain at least one
excluded from pafticipation in or denied any aid, care, feature from each of the three following categories:
service, or other benefits provided by federal and/or . Prevents unauthorized copying of completed or blank
state funding, or otherwise be subjected to any prescription forms.
discrimination . Prevents erasure or modification of information written
. HealthandSafetyCode85.1'l 3as described in "Model on the prescription form.
Workplace Guidelines for Businesses, State Agencies,
and State Contractors" on page G-2 (relating to
. Prevents the use of counterfeit prescription forms.
workplace and confidentiality guidelines on AIDS and
Hlv)
1,.4.7 Utilization Control - General
Exception: ln the case of minors receiving family planning Provisions
services, only the client may consent to release of medical
Title XIX of the Socla/ Security Act, Sections 1902 and
documentation and information. Providers must comply
with the laws and regulations concerning discrimination.
1903, mandates ut¡l¡zation control of all Texas Medicaid
Payments for services and supplies are not authorized
services under regulations found at Title 42 CFR, Part
unless the services and supplies are provided w¡thout 456. Utilization review activities required by Texas
Medicaid are completed through a series of monitoring
discrimination on the bas¡s of race, color, sex, national
systems developed to ensure the quality of services
origin, age, or disability. Send written complaints of
provided, and that all services are both medically
noncompliance to the following address:
necessary and billed appropriately. Both clients and
HHSC Commissioner providers are subject to utilization review monitoring. Utili-
1100 West 49th Street zat¡on control procedures safeguard against the delivery
Austin, TX787563L72 of unnecessary services, monitor quality, and ensure
Reminder: Each provider must furnish covered Medicaid payments are appropriate and according to Texas
services to eligible clients in the same manner, tothe same Medicaid policies, rules, and regulations. All providers
extent, and of the same quality as services provided to identified as a result of utilization control activities are
other patients. Services made available to other pat¡ents presented to HHSC OIG to determine any and all subse-
must be made available to Texas Medicaid clients if the quent actions.
services are benefits of Texas Medicaid. The primary goal of utilization control activity is to identify
providers with practice patterns inconsistent with the
federal requirements and Texas Medicaid scope of
L.4.6 Tamper-Resistant Prescription Pads benefits, policies, and procedures. The use of utilization
Providers are required by federal law (Public Law 110-28) control monitoring systems allows for identification of
to use a tamper+esistant prescription pad when writing a providers whose patterns of practice and use of services
prescription for any drug for Medicaid clients. fall outside of the norm for their peer groups. Providers
identified as exceptional are subject to an indepth review
Providers must take necessary steps to ensure that of all Texas Medicaid billings. These review findings are
tamper-resistant pads are used for all written prescrip- presented to the HHSC OIG to determine any necessary
tions provided to Medicaid cl¡ents. Providers may also use action. Medical records may be requested from the
com plia nt, non-written alternatives for tra ns m¡tting provider to substantiate the medical necessity and appro-
prescriptions such as by telephone, fax, or electronic priateness of services billed to Texas Medicaid.
submittal. Pharmacies are required to ensure that all lnappropriate service utilization may result in recoupment
written Medicaid prescriptions submitted for payment to of overpayments and/or sanctions, or other adminis-
the Vendor Drug Program are written on a compliant trative actions deemed appropriate by the HHSC OlG.
tamper-resistant pad. There are instances when a training specialist may be
lf a prescription is not submitted on a tamper-resistant directed to communicate with the provider to offer assis-
prescription form, a pharmacy may fill the prescription in tance with the technical or administrative aspects of
full on an emergency basis. Texas Medicaid.
The pharmacy must then obtain a verbal, faxed, Atthe direction of the HHSC OlG, a provider's claims may
electronic, or compliant, written prescription from the be manually reviewed before payment. Parameters are
prescriber within 72 hours after the date on which the developed for prepayment review based on the specific
prescription was filled. areas of concern identified in each case. As part of the
Providers may pu rchase ta mper-res ista nt prescri ption prepayment review process, providers are required to
pads from the vendor of their choice. submit paper claims, ratherthan electronic claims, along
with supporting medical record documentation (e.9.,
Special copy+esistant paper is not a requirement for clinical notes, progress notes, diagnostic test¡ng results,
prescriptions printed from electronic medical records other reports, superbills, X-rays, and any related medical
(EMRs) or ePrescribing generated prescriptions. These
record documentation) attached to each claim for all
prescriptions may be printed on plain paper and will be services billed. This documentation is used to ascerta¡n
that the services billed were medically necessary, billed
L-L4 CPT only copyright 2008 American N4edical Association All rights reserued
Denta I
L9.4.2 THSteps Dental Eligibility . Dental prophylaxis, if appropriate
The client must be Medicaid- and THSteps-eligible (birth . Topical fluoride application using fluoride varnish, if
through 20 years ofage) atthe time ofthe service request appropriate
and service delivery. However, Medicaid-approved . Caries risk assessment
orthodontic services already in progress may be continued . Dental anticipatory guidance
even after the client loses Medicaid eligibility if the
orthodontic treatment is begun before the loss of Procedure code D0145 bundles the above services for
Medicaid eligibility and before the day of the client's 21st THSteps clients age 6 months of age through 35 months
birthday and is completed within 36 months. Medicaid- of age. THSteps dentists and Federally Qualified
approved orthodontic services already in progress may be Healthcare Centers (FQHCs) that have completed training
continued even afterthe client loses Medicaid eligibility if and been certified to participate in the First Dental Home
the orthodontic treatment is: initiative may be reimbursed for procedure code D0145.
. FQHC providers attending the training will be certified at
Begun before the loss of Medicaid eligibility
the facility level.
. Begun before the day of the client's 21st birthday
Procedure code D0120, D0150, Dtt2O, D1203, or
. Completed within 36 months. DL206 are denied if procedure code D0145 is billed on
The client is not eligible for THSteps dental preventive or the samê date of service by any provider. A First Dental
therapeutic benefits if the client's Medicaid ldentification Home examination is limited to ten services per client
Form (Form H3087) or Medicaid Eligibility Verification lifetime with at least 60 days between visits. This service
Form (Forms H7O27 and HLO27-A-C) states any of the is limited to once per day.
following:
. Emergency care only
. Presumptive eligibility (PE)
19.5 ICF-MR Dental Services
ICF-MR dental services are mandated by Medicaid, and
. Qualified Medicare beneficiary (QMB) reimbursement is provided for treatment of dental
. Women's Health Program problems for Medicaid-eligible residents of ICF-MR facil-
A check mark will be present ¡n the "Dental" column of the ities who are 2tyears of age or older. Residents of ICF-MR
client's Medicaid ldentification Form (Form H3087) to facilities who are 20 years of age or younger receive
indicate that the client is eligible for dental services. A services through the regular THSteps Program. Eligibility
message (THSteps Dental checkup due) may appear for ICF-MR services is determined þy DADS.
below the client's name on the monthly client Medicaid Procedure codes without a CCP designation in the limita-
ldentification Form (Form H3087) statingthe client is due tions column of the dental fee schedule may be billed in a
for a dental checkup, which serves as a reminder to routine manner for ICF-MR clients.
parents to contact their child's dentist and schedule an
These procedures must be documented as medically
appointment for their periodic dental checkup. This necessary and appropriate. ICF-MR clients are not subject
message is printed on the H3087 when the client has not to periodicity for preventive care.
received any dental services (diagnostic, preventive,
therapeutic, or orthodontic) for a period of six months. For procedure codes with a CCP designation, a provider
may request authorization with documentation or provide
Clients are not eligible for CCP services on or after their documentation on the submitted claim.
21st birthday, but are eligible for non{CP THSteps dental
services (see fee schedule for CCP and nonCCP Refer to: "Medicaid Dental Fee Schedule" on page 19-11.
reimbursed services)through the end of the month of their
21st birthday.
Note: lf a client has a birthday on any day except the first 19.6 THSteps and ¡CF-MR Provision
day during the month, the new eligibility period is of Services
considered to begin on the first day of the following All THSteps and ICF-MR dental services shall be
month. peformed by the Med icaid-en rol led denta I provide r except
for permissible work delegated to a licensed dental
hygienist, dental assistant, or dental technician in a
L9.4.3 First Dental Home dental laboratory on the premises where the dentist
First Dental Home is an initiative designed to establish a practices, or in a commercial laboratory registered with
dental home, provide preventive care, identify oral health the Texas State Board of Dental Examiners (TSBDE). The
problems, and provide treatment and parenlal/ guardian Texas Dental Practice Actand the rules and regulations of
oral health instruct¡ons as early as possible. the TSBDE (22f AC, Part 5) define the scope of work that
dental auxiliary personnel may perform. Any deviations
A First Dental Home visit includes, but is not limited to:
from these practice limitations shall be reported to the
. Comprehensive oral examination TSBDE and HHSC, and could result in sanctions or other
. Oral hygiene instruction with primary caregiver actions imposed agalnst the provider.
CDf only copyíght 2008 American Dental Association- All rights reseryed 19-5
Section 19
19.18 Hospitalization and ASG/HASC Exception: Retained deciduous teeth and cleft palates
with gross malocclusion that will benefit from early
Dental services performed in an ASC, hospital ambulatory treatment. Cleft palate cases do not have to meet the HLD
surgical center (HASC), or a hospital (either as an 26-point scoring requirement. However, it is necessary to
inpatient or an outpatient) may be benefits of THSteps submit a sufficient narrative and,/or outline of the
based on the medical or behavioraljustification provided, proposed treatment plan when request¡ng authorization
or if one of the following conditions exist: for orthodontic services on cleft palate cases,
. The procedures cannot be performed in the dental . Crossbite therapy.
office.
. . Head injury involving severe traumatic deviation.
The client is severely disabled.
The following l¡mitat¡ons apply for orthodontic services:
Contact the individual HMO for precertification require-
ments related to the hospital procedure. lf services are
. Orthodontic services for cosmetic purposes only are
precertified, the provider receives a precertification not a benefit of Texas Medicaid or THSteps.
number effective for 90 days. . Orthognathic surgery, to include extractions, required or
ln those areas of the state with Medicaid managed care, provided in conjunction with the application of braces
the provider should contact the managed care plan for must be completed while the client is Medicaid-eligible
specific requirements or limitations. lt is the dental in order for reimbursement to be considered.
provider's responsibility to obtain precertification from the . Except for D8660, all orthodontic procedures require
client's HMO or managed care plan for facility and general prior authorization for consideration of reimbursement.
anesthesia services if it is required. . The THSteps client must be Medicaid/THSteps€ligible
To be reimbursed by the HMO, the provider must use the when authorization is requested and the orthodontic
HMO's contracted facility and anesthesia provider. These treatment plan is initiated. lt is the provider's responsi-
services are included in the capitation rates paid to bility to see that the client has a current Medicaid
HMOs, and the facility/anesthesiologist risk nonpayment ldentification Form (Form H3087) or Medicaid Eligibility
from the HMO without such approval. Coordination of all Verification Form (Forms HLO27 and H1O27-A-C) and
specialty care is the responsibility of the client's primary that the date of birth on the form indicates the client ¡s
care provider. The primary care provider must be notified 20 years of age or younger and no limitations are
bythe dentist and/or the HMO of the planned services. indicated.
Dentists providing sedation/anesthesia services must . Prior authorization is issued to the requesting provider
have the appropriate current permit from the TSBDE for only and is not transferable to another provider. lf the
the level of sedation/anesthesia provided. client changes providers or if the provider stops
The dental provider must be in compliance with the guide- practicing dentistry in Texas Medicaid for whatever
lines detailed in "Dental Therapy Under General reason, a new prior authorization must be requested.
Anesthesia" on page 19-35. Refer to: "Transfer of Orthodontic Services" on page 19-
Note: Post-treatment authorization will not be approved 40.
for codes that require mandatory prior authorization. The following procedure codes, policies, and limitations
are applied to the processing and payment of o¡thodontic
services under THSteps dental services:
19.19 Orthodontic Services . Procedure code D8660 is allowed when:
(THSteps) . The client is referred to an ofthodontistfora determi-
Orthodontic services for cosmetic purposes only are not a nation of whether orthodontic services are indicated
benefit of Texas Medicaid. Orthodontic services are and to determine the appropriate time to initiate
limited to the treatment of children t2years of age or such services.
older with severe handicapping malocclusion, children . The client is referred to an ofthodontist and elects to
birth through 20 years of age with cleft palate, or other receive services from another orthodontic provider
special medically necessary circumstances as outlined in because of justifiable reasons.
Benefits and Lim¡tations below.
. Repeat visits at different age levels are required to
determine the appropriate time to initiate
19.19.1 Benefits and Limitations orthodontic treatme nt.
Orthodontic services include the following:
. Procedure code D8680 is payable for one retainer per
arch, per lifetime, and each retainer may be replaced
. Correction of severe handicapping malocclusion as once because of loss or breakage (prior authorization is
measured on the Handicapping Labiolingual Deviation required).
(HLD) lndex. Refer to page 79-45 for information on
how to score the HLD. A minimum score of 26 points is
. Procedure code D8670 should be billed only when an
required for full banding approval (only permanent adjustment to the appliances is provided and may not
dentition cases are considered). be billed before the date the orthodontic adjustment
was performed. The number of visits for monthly adjust-
19-38 CDf only copyright 2O08 American Denta¡ Assoc¡at¡on All righls reseryed
Dental
ments to the appliances is restricted to the number L9.L9.2 Mandatory Prior Authorization
that was authorized in the treatment plan. However, the Prior authorization is required for all THSteps orthodontic
number of monthly visits may be amended with appro- services except for procedure code D8660. The prior
priate documentation of medical necessity while the authorization request must contain the DOS that the
client is Medicaid eligible. orthodontic diagnostic tools were produced. lf the request
. Procedure code D8670 is paid only in conjunction with is approved, the date that the records were produced is
a history of braces (code 08080), unless special considered to be the date on which orthodontic treatment
circumstances exist. begins.
. All orthodontic codes and appliances are global fees. Refer to: "THSteps Dental Mandatory Prior Authorization
. Request Form" on page 8-111.
Separate fees for adjustments to retainers are not
payable. lf orthodontic treatment is medically indicated, providers
. The appropriate code should be billed for those appli- are responsible for obtaining prior authorization for a
ances required as part of the treatment of cleft palate complete orthodont¡c treatment plan while the client is
cases. eligible for Medicaid and THSteps and 20 years of age or
younger.
Special orthodontic appliances may also be used with full
banding and crossbite therapy with approval by the TMHP Submission of diagnostic casts are not required when
Dental Director. requesting prior authorization for procedure codes
08050, D8060, or D8080.
. Procedure codes D5951, 05952, D5953, D5954,
Prior authorization is a condition for reimbursement; it is
D5955, D5958, D5959, and D5960 are to be used as
applicable with documentation of medical necessity. not a guarantee of payment.
Otherwise, use the appropriate special orthodontic Upon receipt of prior authorization of complete treatment
appliance code. plans, providers are to advise clients that they will be able
. Full banding is allowed on permanent dentition only, to receive the approved treatment services (e.9.
and treatment should be accomplished in one stage orthodontic adjustments, bracket replacements and
and is allowed once per lifetime. retainers), even if they lose Medicaid elieiibility or reach
27 years of age. Approved ofthodontic treatment must be
Exception: Cases of mixed dentition when the treatment initiated before the loss of Medicaid eligibility and
plan includes extractions of remaining primary teeth or completed within 36 months of the authorization date.
cleft palate.
Note: Providers must submit all orthodontic services for
. Crossbite therapy is allowed for primary, mixed, or Medicaid managed care clients following these guide'
permanent dentition. lines. STAR and STAR+PLUS are not responsible for
. Providers must not request crossbite correction (limited orthodontic services.
orthodontics) for a mixed dentition client when there is Requests for orthodontic services must be accompanied
a need for full banding in the adult teeth. Crossbite by all of the following documentation:
therapy is an inclusive charge for treating the crossbite . An orthodontic treatment plan. The treatment plan
to complet¡on, and additional reimbursement is not
provided for adjustments or maintenance.
must include all procedures required to complete full
treatment (such as, extractions, ofthognathic surgery,
. lf a case is not approved, the dentist may file a claim upper and lower appliance, monthly adjustments, ant¡c-
for payment of the diagnostic workup necessary to ipated bracket replacements, appliance removal if
obta¡n the authorization using procedure codes D0330, indicated, special orthodontic appliances, etc.). The
D0340, D0350, and D0470. The dentist may receive treatment plan should incorporate only the minimal
payment underthese procedure codes for no more than number of appliances required to properly treat the
two cases out of every ten cases denied. The dentist case. Requests for multiple appliances to treat an
should determine if the client's condition meets individual arch are reviewed for duplication of purpose.
orthodontic benefit criteria before performing a . Cephalometric radiograph with tracing models.
diagnost¡c workup.
. . Completed and scored HLD sheet with diagnosis of
Procedure codes D8080, D8O5O, and 08060, are
Angle class (26 points required for approval of noncleft
limited to one per lifetime.
palate cases).
. Comprehensive orthodontic services (procedure code . Facial photographs.
D8080) are restricted to clients who are !2 years of
age or older or clients who have exfol¡ated all primary . Full series of radiographs or a panoramic radiograph;
dentition. Crossbite therapy includes diagnosic cast diagnosticauality films are required (copies are
services. accepted and radiographs will not be returned to the
provider).
CDT only copyright 2008 American Dental Association All rjghls reseryed 19-39
Section 19
. Any additional pertinent information as determined by The following supporting documentation must accompany
the dent¡st or requested by TMHP's Dental Director the new request for orthodontia services and must include
Requests for crossbite therapy require properly the DOS the ofthodontic diagnostic tools were produced:
trimmed models to be retained in the office and must . All of the documentation as required for the original
demonstrate the following criteria: provider.
. Posterior teeth. Not end to end, but buccal cusp of . The reason the client left the previous provider, if
upper teeth should be lingual to buccal cusp of lower known.
teeth.
. An explanation of the treatment status.
. Anterior teeth. The incisal edge of upper should be
.
lingual to the incisal of the opposing arch. A compete treatment plan addressing all procedures for
which authorization is being requested (such as the
The dentist should be certain that radiographs, photo- number of monthly adjustments or reta¡ners required to
graphs, and other information are properly packaged to complete the case).
avoid damage. TMHP is not responsible for lost or
damaged materials.
. A full diagnostic workup (D8080) with an HLD lndex.
The score of 26 points will be modified according to any
Refer to: "THSteps Dental Mandatory Prior Authorization progress achieved.
Request Form" on page 8-111.
Exception:The prior authorization requests for clients
who initiate orthodontic services before becoming eligible
19.19.3 Gompletion of Treatment Plan for Medicaid do not requ¡re models or the HLD score
sheet, nor does the client have to meet the HLD lndex of
lf a client reaches 2tyears of age or loses Medicaid eligi- 26 points, However, a complete plan of treatment is
bility before the authorized orthodontic treatment is required.
completed, reimbursement is provided to complete the
orthodontic treatment that was authorized and initiated Note: Medicaid clients who initiate orthodontic services
while the client was 20 years of age or younger, eligible for privately (e.9. pay out of pocket for the ofthodontic workup
Medicaid and THSteps, and completed within 36 months. and/or ¡n¡t¡al banding, etc.) wh¡le Medicaid eligible due to
Any orthodontic-related service requested (e.9., extrac- not meeting the HLD index 26-points, are not eligible to
tions or surgeries) must be completed before the loss of have their orthodontic services transferred to and
client eligibility. Serv¡ces cannot be added or approved reimbursed by Medicaid.
after Medicaid/THSteps eliÉibility has expired. To request prior authorization for completion of the
orthodontic treatment initiated by another provider,
complete a THSteps Dental Mandatory Prior Authorization
L9.L9.4 Premature Removal of Appliances Request Form and send it with the complete plan of
The overall fee for orthodontic treatment (D8080) treatment and appropriate documentation for orthodontic
includes the removal of orthodontic brackets and/or services and/or crossbite therapy to the TMHP Dental
treatment appliances. Procedure code D7997 may be Director at the following address:
used only when the appliances were placed by a different Texas Medicaid & Healthcare Partnership
provider with an unaffiliated practice (not a partner or THSteps and ICF-MR Dental Authorization and lnformation
office-sharing arrangement) and one of the following PO Box 2O29L7
conditions exist: Austin, TX 78720-2977
. There is documentation of a lack of cooperation from
the client.
. The client requests premature removal and a release
19.19.6 Gomprehens¡ve Orthodontic
form has been signed by the parent, guardian, or client Treatment
if he is at least 18 years of age. Comprehensive orthodontic services (procedure code
D8080) are restricted to cl¡ents who are t2years o1 age
Providers must keep a copy of the release form on file and
or older or clients who have exfoliated all primary
are responsible for this documentation during a review
dent¡tion.
process.
National procedure codes do not allow for any work-in-
progress or partial billing by separating the three
19.19.5 Transfer of Orthodontic Services orthodontic components: diagnostic workup, orthodontic
Prior authorization issued to a dental provider for
appliance (upper), or orthodontic appliance (lower).
orthodontic services is not transferable to another dental When billing for comprehensive orthodontic treatment,
provider. The new provider must subm¡t to TMHP a new D8080, three local codes must be submitted as remarks
prior authorization request in order to be approved to codes along with code D8080. Local codes (72OO9,
complete the orthodontic treatment initiated by the Dia gnostic worku p a pproved, Z2OI1-, O rthodontic
original provider.
19-40 CDf only copyright 2008 Ame.ican Dental Association. All rights reseryed
De nta I
appliance, upper, or Z2OL2, Orthodontic appliance, lower) are placed in the Remarks Code field on
electronic claims or Block 35 on paper claims.
Note: lf the remarks code and procedure code D8080 are not subm¡tted, the claim will be denied.
Each remarks code pays the correct reimbursement rate which, when combined, totals the maximum
payment of $775. D8080 must be billed on three separate details, with the appropriate remarks code,
even if billing for the workup and full banding. Billing only one detail for a total of $775 will not be
accepted.
Example 1: A client is approved forfull banding, but afterthe initial workup, the client discontinues
treatment. This provider would billthe national code D8080 and place the local code 22009, Diagnostic
workup approved, in the Remarks/comment field. The claim would pay $175.
Example 2: A client is approved forfull banding. The provider continues treatment and places the
maxillary bands. The provider would bill the national procedure code D8080 and place the local code
Z2OO9, Diagnostic workup approved, and 2201,1, Maxillary bands, in the Remarks/comment field. The
claim would pay $475.
All electronic claims for D8080 must have the appropriate remarks code associated with the procedure
code.
Providers should adhere to the following guidelines for electronic claim submission so that TMHP can
accurately apply the correct remarks code to the appropriate claim detail.
A Diagnostic Procedure Code (DPC) remarks code must be submitted, only once, in the first three bytes
of the NTE02 at the 2400 loop.
Example 1: For a claim with one detail, submitted with procedure code D8080 and remarks code
Z2OO9, enter the information as follows: DPCZ2OO). The total billed would be $175.
Example 2=For a claim with two details, where details one and two are procedure code D8080 and the
remarks codes are Z2OO9 andZ2Ott, enter the information as follows: DPCZ2OO9Z2011. The total
billed would be $475.
Example 3: Fora claim with three details, where all three details are subm¡tted separatelywith
procedure code D8080, enter the remarks code based on the order of the claim detail as follows:
DPCZ2OO972OI7Z2O72. The total billed would be $775.
This method ensures accurate and appropriate paymentforservices rendered and addresses the need
for partial billing.
L9.L9.7 Orthodontic Procedure Codes and Fee Schedule
When submitting claims for orthodontic procedures, use the following procedure codes
Procedure Code' Limitations Maximum Fee
D0330*, When requested ofthodontic cases are subm¡tted for authorization $100.00
D0340*, and denied, two out of ten denials will be paid. These four
D0350*, and procedure codes, when billed together for denied cases, replace
DO470* local procedure code Z2OLO.
D7280 A t-20 $62.50
D7997* Replaces Z2016. Not payable to the dentist who placed the $50.00
appliance. lncludes removal of arch bar and premature removal of
braces. A 1--2O
lnterceptive OrthodontÍc Treatment
D8050* Replaces Z2OI8 and 8110D. Limited to one per lifetime. $340.00
D8060* ' Replaces Z2OI8 and 8120D. Limited to one per lifetime. $340.00
D8080* , Rep laces 22009, Z2OL1-, and 22072. Limited to one per lifetime. $775.00
Minor Treatment to Control Harmful Habits
D82rO* See separate table for associated remarks field code. See separate
table
* = Selices payable to an FQHC for a cl¡ent encountet
CDT only copyright 2008 Amercan Denta Association All righls reserued t94t
Section 19
ProcedureGode Limitations Maximum Fee
D8220* See separate table for associated remarks field code. See separate
table
Other Orthodont¡c
D8660* Replaces Z2QO8. Denied when bill on the same DOS as D0145. $15.00
Replaces Z2OL3 $68.10
Replaces Z2OI4 and Z2OI5; one retainer per arch per lifetime; $100.00
may be replaced once because of loss or breakage (prior authori-
zation is required)
D8690* Bracket replacement. $20.00
D8691 Not considered medically necessary NC
D8693 $50.00
D8999 Manually
priced
* = Services payable to an FQHC for a client encounter
L9.2O Special Orthodontic Appliances
As with all otthodontic services, all removable or fixed special orthodontic applicances must be prior
authorized. The prior authorization request must include both the national code and remarks code.
However, prior authorizat¡on requests may omit the DPC prefix to the eight¡igit remarks code.
All removable orfixed special orthodontic appliances must be billed with national procedure code
DA21O or D822O. Dental models must be submitted when requesting prior authorization of a thumb-
sucking ortongue thrust appliance. To ensure appropriate claims processing, the DPC remarks code
(local procedure code) reflecting the specific service is also required. The appropriate remarks codes
must be entered on the authorization request form. Failure to follow the following steps will cause the
claims to deny. Failure to enter the DPC remarks code and the appropriate procedure code will not result
in claim denial; however, manual intervention is required to process the claim, which may result ¡n a
delay of payment.
For paper claim submissions, providers must enterthe local procedure code in Block 35 (Remarks) of
the 2006 ADA claim form.
For electronic submissions, providers enter the DPC remarks code in the Comments field to ensure
correct a uthorization, accu rate records, a nd re i m bu rsement.
For electronic submissions other than TexMedConnect submissions, providers must follow the steps
below to ensure TMHP accurately applies the correct local procedure code to the appropriate claim
detail:
1) The DPC prefix must be submitted, only once, in the firstthree bytes of the NTE02 atthe 2400
loop.
2) ln bytes 4-8, providers must submit the remark code (local procedure code) based on the order of
the claim detail. Do not enter any spaces or punctuat¡on between remark codes, unless to
designate the detail is not billed with D8210 or D822O.
Example: For a claÌm with three details, where details one and three are subm¡tted with procedure code
D8210 and detail two ¡s not, enter the following information in the NTE02 at the 2400 loop: DPC| 01 4D
1046D. (The space shows that detail two needs no local code.) lf all details require a local code, enter
DPC, no spaces, and the appropriate local codes,
To submit using TexMedConnect, providers must enter the local code into the Remarks Code field,
located underthe details header. The Remarks Code field is the field directly afterthe Procedure Code
field. TexMedConnect submitters are not required to manually enter the DPC prefix as it is placed in the
appropriate field on the TexMedConnect electronic claim.
L942 CDT only copyríght 2008 Amercan Dental Associatron All íghts reseryed
Dental
L9.2L How to Score the Handicapping Labio-lingual Deviation (HLD)
lndex
The orthodontic provider must complete and sign the diagnosis (Angle class).
Cleft Palate
Submit a cleft palate case in the mixed dentition only if it can be justified in a narrative why there should
be treatment before the client is in the full dentition.
Note: lntermittent treatment requests may exceed the allowable 26 reimbursable treatment visits.
Severe Traumatic Deviations
Refers to facial accidents only. Po¡nts cannot be awarded for congenital deformity. Severe traumatic
deviations do not include traumatic occlusions for crossbites.
Overjet in Millimeters
Score the case exactly as measured, then subtract 2 mm (considered the norm), and enterthe
difference as the score.
Overbite in Millimeters
Score the case exactly as measured, then subtract 3 mm (considered the norm), and enter the
difference as the score. This would be doublecounting.
Mandibular Protrusion in Millimeters
Score the case by measurement in mm bythe distance from the labial surface of the mandibular
incisors to the labial surface of the maxillary incisor. Do not score both overbite and open bite.
Open Bite in Millimeters
Score the case exactly as measured. Measurement should be recorded from the line of occlusion of
the permanent teeth, not from ectopically erupted teeth in the anterior segment. Caution is advised in
undertaking treatment of open bites in older teenagers, because of the frequency of relapse.
Ectopic Eruption
An unusual pattern of eruption, such as high labial cuspids orteeththataregrosslyoutof the longaxis
of the alveolar ridge. Do not include (score) teeth from an arch if that arch is to be counted in the
following category of Anterior Crowding. For each arch, either the ectopic eruption or anterior crowding
may be scored, but not both.
Anterior Crowding
Anterior teeth that require extractions as a prerequisite to gain adequate room to treat the case. lf the
arch expansion is to be implemented as an alternative to extraction, provide an estimated number of
appointments required to attain adequate stabilization. Arch length insufficiency must exceed 3.5 mm
to score for crowding on any arch. Mild rotations that may react favorably to stripping or moderate
expansion procedures are not to be scored as crowded.
Labio-lingual Spread in millimeters
The score forthis category should be the total, in millimeters, of the anterior spaces.
Providers should be conservative in scoring. Liberal scoring will not be helpful in the evaluation and
approval of the case. The case must be considered dysfunctional and have a minimum of 26 points on
the HLD index to qualify for any orthodontic care other than crossb¡te correction. Half-mouth cases
cannot be approved.
The intent of the program is to provide orthodontic care to cl¡ents with handicapping malocclusion to
improve function. Although aesthetics is an important part of self-esteem, services that are primarily
for aesthetics are not within the scope of benefits of this program.
The proposals for treatment services should incorporate only the minimal number of appliances
required to properlytreatthe case. Requests for multiple appliances to treat an individual arch will be
reviewed for duplication of purpose.
lf attaininga qualifyingscore of 26 points is uncertain, providers should include a brief narrative when
submittingthe case. The narrative may reduce the time necessaryto gain final approval and reduce
shipping costs incurred to resubm¡t records.
Providers must properly label and protect all records (especially plaster diagnostic models) when
shipping. lf plaster diagnostic models are requested by and shipped to TMHP, the provider should
assure that the models are adequately protected from breakage during shipping. TMHP will return intact
models to the prov¡der.
CD-f only copyright 2008 Ameícan Dental Associataon. All rights reseryed 19-45
Section 19
L9.2L.L HLD Score Sheet
This sheet and a Boley Gauge are required to score.
Procedure:
. Occlude client or models in centric position.
. Record all measurements rounded-off to the nearest millimeter.
. Enter a score of 0 if the condition is absent.
. Overjet is measured from the most protrusive inc¡sor.
. Overbite is measured from the labio-incisal edge of overlapped anterior tooth or teeth to point of
maximum coverage.
. Ectopic eruption and anterior crowding: Do not double-score. Record the more serious condition.
PLEASE PRINT CLEARLY:
Client Name: Date of birth Medicaid lD:
Address: (Street/City/County/State/Zip Code)
CONDITIONS OBSERVED HLD SCORE
Cleft Palate Score 15
Severe Traumatic Deviations Score 15
Trauma/Accident related only
Overjet in mm. Minus 2 mm.
Example: I mm. - 2 mm. = 6 points
Overbite in mm. Minus 3 mm.
Example: 5 mm. - 3 mm. = 2 points
Mandibular Protrusion in mm. x5
See definitions/instructions to score (previous page)
Open Bite in mm. x4
See definitions/instructions to score (previous page)
Ectopic Eruption (Anteriors Only) Each tooth x3
Reminder: Points cannot be awarded on the same arch
for Ectopic Eruptíon and Crowding
Anterior Crowding Max. Mand = 5 pts. each
1O point maximum total for both arches arch
combined
Labio-lingual Spread in mm
TOTAL
Diagnosis For TMHP use only
Authorizat¡on Number
Examiner: ,Recorder:
Provider's Signature
Please submit this score sheet with records
19-46 CDI only copyr¡ght 2008 American Dental Associatron All ri8hts reserued
Appendix G
Dear Manual User:
Welcome to the 2OO8 Texas Medicaid Provider Procedures Manual. To enhance usability, this manual
is available on a searchable CD-ROM and on the TMHP website at www.tmhp.com.
Note: Atl users who access www.tmhp.com are required to accept the American Medical Association
(AMA) End-user Agreement on the use of Current ProceduralTerminology (CPT). For each computer that
accesses the TMHP website, the agreement must be accepted every 30 days from the last date on
which the agreement was accepted by the user. lf the end-user agreement is not accepted on a
par-ticular computer every 30 days, no user will be able to enter the website from that computer. For
add¡t¡onal information about the AMA and CPT, refer to www.ama'assn.org/ama/pub/category
/31-73.html.
A C/aims FitinS Resourcestable is located at the end of each service section with page references to all
claim instructions, appendices, Medicaid forms, and claim form examples associated with the service.
This manual contains both the Primary Care Case Management (PCCM) and Texas Health Steps
(THSteps) manuals. PCCM information can befound primarily in Section 7, though relevant informatlon
can be found in other sections. THSteps information is contained in Section 43 and throughout the
manual.
The Texas Medicaid Program policy published in this manual represents policy implemented as of
October 31,,2OO7. Policy updates effective after October 3L,2OO7, are published bimonthly in the
Texas Medicaìd Bu lletin.
The November/December 2OO7 Texas Medicaid Bulletin and all Texas Medicaîd Bulletins through and
including the September/October 2008 lexas Medicaid Bulletin supplement the 2008 Texas Medicaid
Provider Procedures Manual and update the policy contained herein'
The fexas Medicaid Provider Procedures Manual serves as a comprehensive guide for Texas Medicaid
providers, and contains information aboutTexas Medicaid benefits, policies, and procedures. The
manual also includes an overyiew of the State of Texas Medicaid lvlanaged Care programs to include
the State of Texas Access Reform (STAR), STAR+PLUS, PCCM, and NorthSTAR. The information
regardingthe State of Texas Medicaid Managed Care programs, including Section 7, is not an
exhaustive policies ancl procedures guide. For specific managed care informat¡on, contact the individual
heatth plans participating in STAR, STAR+PLUS, and NorthSTAR. For PCCM, refer to the TMHP
Telephone and Address Guide included in this manual.
Provider Manual Overview
The 2OO8 Texas Medicaid Provider Procedures Manual is divided into three parts, including
Part l: Provider lnformation
The information in Part I is for all health-care providers who are enrolled in the Texas Medicaid Program
and provide services to Texas Medicaid clients. ln Part l, providers find instructions for providing
allowable services and receiving appropriate reimbursement for services. The following sections are
included in Part l:
. lntroduction.
. TlvlHP Telephone and Address Guide.
. Section 1. Provider Enrollment and Responsibìlitres.
. Sect¡on 2. Texas lvledicaid Reimbursement.
. Section 3. TMHP Electronic Data lnterchange (EDl).
. Section 4. Client EligibilitY.
. Sect¡on 5. Claims Filing.
. Section 6. Appeals.
. Section 7. Mana1ed Care.
Part ll: Texas Medicaid Services
Part ll contains a section for each Texas Medicaid service with information on health-care policy, proce-
dures, and claims filing pertaining to each provider type.
CPT only copyíght 2OO7 Ar¡eilca¡ lvledlcal All rlghts reserued
^ssocratron
Section 1
documents or other requested items may be altered or 1,.2.4 Release of Gonfidential lnformation
destroyed, the reguest must be completed by the prov¡der lnformation about the diagnosis, evaluat¡on, or treatment
at the t¡me of the request or in less than 24 hours as of a client with Texas Medicaid Program coverage by a
provided by the requestor. lf , in the opinion of the lnspector person licensed or certified to peform the diagnosis,
General or other requestor, the requested documents and evaluation, or treatment of any medical, mental, or
other items requested cannot be completely provided on emotional disorder, or drug abuse, is confidential infor-
the day of the request, the ,nspector General or requestor mation that the provider may disclose only to authorized
may set the deadline for production at 24 hours from the people. Family planning information is sensitive, and
t¡me of the orig¡nal reguest. confidentiality must be ensured for all clients, especially
Failure to supply the reguested doc uments and other items, mtnors.
w¡thin the time frame specified, may result in payment hold Only the client may give written permission for release of
to the provider's Medicaid payments, recoupment of any pertinent information before client information can be
payments for all claims related to the miss¡ng records,
released, and confidentiality must be maintained in all
contract cancellation, and/or exclusion from the Texas other respects. lf a client's medical records are requested
Medicaíd Progiram. by a licensed Texas health-care provider or a physician
As directed by the requestor, the provider or person will licensed by any state, territory, or insular possession of
relinquish custody of the requested documents and other the United States or any State or province of Canada, for
Items and the requestor will take custody of the records purposes of emergency or acute medical care, a provider
and remove them from the premises. lf the requestor must furnish such records at no cost to the requesting
should allow longer than "at the time of the request" to provider. This includes records received from another
produce the records, the provider will be required to physician or health{are provider involved in the care or
produce all records completed, at the time of the treatment of the patient. lf the records are requested for
completion or at the end of each day of production, as purposes other than for emergency or acute medical care,
directed by the requestor who will take custody of the the provider may charge the requesting provider a
requested items. reasonable fee and retain the requested information until
payment is received.
lf the provider places the required information in another
legal entity's records, such as a hospital, the provider is The client's signature is not required on the claim form for
responsible for obtaining a copy of these requested payment of a claim, but HHSC recommends the provider
records for use by the requesting state and federal obtain written authorization from the client before
agencies. releasing confidential medical information. A release may
be obtained by having the client s¡gn the indicated block
These documents and claims must be retained for a
on the claim form after the client has read the statement
minimum period of five years from the date of service or
of release of information that is printed on the back of the
until all audit quest¡ons, appeal hearings, investigations,
or court cases are resolved. Freestanding RHCs must form. The client's authorization for release of such infor-
retain their records for a minimum of six years, and mation is not required when the release is requested by
and made to DADS, HHSC, DSHS, TMHP, DFPS, DARS,
hospital-based RHCs must retain their records for a
HHSC OlG, the Texas Attorney General's MFCU or
m¡nimum of ten years. These records must be made
available immediately at the time of the request to
Antitrust and Civil Fraud Division, or HHS.
employees, agents, or contractors of HHSC Offìce of
lnspector General (OlG), the Texas Attorney General's
Medicaid Fraud Control Unit (MFCU) or Antitrust and Civil
L.2.5 Compliance w¡th Federal Legislation
Medicaid Fraud Section, TMHP, DFPS, the Department of HHSC complies with HHS regulations that protect against
Aging and Disability Services (DADS), Department of State discrimination. All contractors must agree to comply with
Health Services (DSHS), Department of Assistive and the following:
Rehabilitative Services (DARS), U.S. Department of Health . Tiile Vl of the civil Ri$hts Act of 7964 (Public Law
and Human Services (HHS) representative, any state or 88-352), Section 504 of the Rehabilitat¡on Act of 7973
federal agency authorized to conduct compliance, (Public Law 93-112), The Americans with Disabilities Act
regulatory, or program integrity functions on the provider, of 7990 (Public Law 101-336), T¡tle 40, Chapter 73, of
person, or the services rendered by the provider or the TAC, all amendments to each, and all requirements
person, or any agent, contractor, or consultant of any imposed by the regulations issued pursuant to these
agency or division delineated above. ln addition, the acts. The laws provide ¡n part that no persons in the
provider must meet all requirements of 1 TAC, Part 15, U.S. shall, on the grounds of race, color, national or¡gin,
s371.1643(f). age, sex, disability, political beliefs, or rel¡gion, be
The records must be available as requested by each of excluded from participation in or denied any aid, care,
these entities, during any investigation or study of the service, or other benefits provided by federal and/or
appropriateness of the Medicaid claims submitted by the state funding, or otherwise be subjected to any
provider. discrimination.
1-8 cPl only copyright 2007 Amer¡can Medical Association All rights reseryed
Provider Enrollment and Responsibil¡ties
. Health and Safety Code 85.773 as described in "Model be directed to communicate with the provider to offer
Workplace Guidelines for Businesses, State Agencies, assistance with the techn¡cal or administrative aspects of
and State Contractors" on page G-2 (relating to the Texas Medicaid Program.
workplace and confidentiality guidel¡nes on AIDS and At the direction of the HHSC OlG, a provider's claims may
Hrv). be manually reviewed before payment. Parameters are
Exception: ln the case of minors receiving family planning developed for prepayment review based on the specific
services, onlythe cl¡ent may consentto release of medical areas of concern identified in each case. As part of the
documentation and information. Providers must comply prepayment review process, providers are required to
with the laws and regulat¡ons concerning discrimination. submit paper claims, rather than electronic claims, along
Payments for services and supplies are not authorìzed with supporting medical record documentation (e.9.,
unless the services and supplies are provided without clinical notes, progress notes, diagnost¡c testing results,
discrimination on the basis of race, color, sex, nat¡onal other reports, superbills, X-rays, and any related medical
or¡g,¡n, age, or disability. Send written complaints of record documentation) attached to each claim for all
noncompliance to the following address: services billed. This documentation is used to ascerta¡n
that the services billed were medically necessary, billed
HHSC Commissioner
appropriately, and according to Texas Medicaid Program
11OO West 49th Street
requirements and policies. Services inconsistent with
Austin, ÍX78756-3]-72
Texas Medicaid Program requirements and policies are
Reminder: Each provider must furnish covered Medicald adjudicated accordingly. C la ims su bm itted initial ly without
services to eligible clients in the same manner, to the same the supporting medical record documentation will be
extent, and of the same quality as services provided to denied. Additional medical record documentation
other pat¡ents. Services made available to other patients submitted by the provider for claims denied as a result of
rnust be made available to lexas Medlcaid clients if the the prepayment review process is not considered at a
services are benefits of the Texas Medicaid Proglram. later time. A provider is removed from prepayment review
only when determined appropriate by the HHSC OlG. Once
removed from prepayment review, a follow-up assessment
1,.2.6 Utilization Control General ofthe provider's subsequent practice patterns is
Provisions - performed to monitor and ensure continued appropriate
T¡tle XIX of the Social Security Act, Sections 1902 and use of resources. Noncompliant providers are subject to
1903, mandates utilization control of all Texas Medicaid administrative sanctions up to and includ¡ng exclusion
Program services under regulations found at Title 42 CFR, and contract cancellation, as deemed appropriate by the
Part 456. Utilization review activities required by the Texas HHSC OIG as defined in the rules in 1 TAC 9371.1643.
Medicaid Program are completed through a series of Providers placed on prepayment review must submit all
paper claims and supporting medical record documen-
monitoring systems developed to ensure the quality of
services provided, and that all services are both medically tation to the following address:
necessary and billed appropriately. Both clients and Texas Medicaid & Healthcare Partnership
providers are subject to utilization review monitor¡ng. Utili- Attention: Prepayment Review MC-411 SURS
zation control procedures safeguard against the delivery PO Box 203638
of unnecessary seruices, monitor quality, and ensure Austin, Texas 78720-3638
payments are appropriate and according to Texas
Medicaid Program policies, rules, and regulations. All
providers identified as a result of utilization control activ- 1-.2.7 Provider Gertification/Ass¡gnment
ities are presented to HHSC OIG to determine any and all Texas Medicaid service providers are required to certify
subsequent actions. compliance with or agree to various provisions of state
The primary goal of utilization control activity is to identify and federal laws and regulations. After submitting a
providers with practice patterns inconsistent with the signed claim to TMHP, the provider certifies the follow¡ng:
federal requirements and the Texas Medicaid Program . Services were personally rendered by lhe billing
scope of benefits, policies, and procedures. The use of provider or under the personal supervision of the billing
utilization control monitoring systems allows for identifi- provider, if allowed for that provider type, or under the
cation of providers whose patterns of practice and use of substitute physician arrangement.
services fall outside of the norm for their peer groups.
Providers identified as exceptional are subject to an in-
. The information on the claim form is true, accurate, and
depth review of all Texas Medicaid billings. These review complete.
findings are presented to the HHSC OIG to determine any . All services, supplies, or items billed were medically
necessary action. Medical records may be requested from necessary for the client's diagnosis or treatment.
the provider to substantiate the medical necessity and Exception is allowed for special preventive and
appropriateness of services billed to the Texas Medicaid screening programs (for example, family planning and
Program. lnappropriate service utilization may result in Texas Health Steps [THSteps]).
recoupment of overpayments and/or sanctions, or other : Medical records document all services billed and the
administrative actions deemed appropriate by the HHSC medical necessity of those services.
OlG. There are instances when a tra¡ning specialist may
CPT only copyright 2OO7 American lvedical Assæ¡ation All r¡ghts reseryed 1-9
Section 19
with gross malocclusion that will benefit from early
L9.L7 Hospitalization and ASG/HASC treatment. Cleft palate cases do not have to meetthe HLD
Dental services performed in an ASC, hospital ambulatory 26-po¡nt scoring requirement. However, ¡t is necessary to
surgical center (HASC), or a hospital (either as an submit a sufficient narrative and/or outline of the
inpatient or an outpatient) may be benefits of THSteps on proposed treatment plan when requesting author¡zat¡on
the medical or behavioral justification provided, or if one for orthodontic services on cleft palate cases.
of the following conditions exist:
. The procedures cannot be performed in the dental . Crossþite therapy.
office.
. Head injury involving severe traumatic deviation.
. The client is severely disabled. The following limitations apply for orthodontic services:
Contact the individual HMO for precertification require-
. Orthodontic services for cosmetic purposes only are
ments related to the hospital procedure. lf services are not a benefit of the Texas Medicaid Program or
precertified, the provider receives a precertification THSteps.
number effective for 90 days. . Orthognathic surgery, to include extractions, required or
ln those areas of the state with Medicaid Managed Care, provided in conjunction with the application of braces
precertification or approval is required from the client's must þe completed while the client is Medicaid-eligible
HMO for anesthesia and facility charges. lt is the dental in order for reimbursement to be considered.
provider's responsibility to obtain precertification from the . Except for D8660, all orthodontic procedures require
client's HMO or managed care plan for facility and $eneral prior authorization for consideration of reimbursement.
anesthesia services. . The THSteps client must be Medicaid/THSteps-eligible
To be reimbursed by the HMO, the provider must use the when authorization is requested and the orthodontic
HMO's contracted facility and anesthesia provider. These treatment plan is initiated. lt is the provider's responsi-
services are included in the capitation rates paid to bility to see that the client has a current Medicaid
H MOs, and the faci ity,/anesthesiologist risk nonpayment
I ldentification Form (Form H3087) or Medicaid Eligibility
from the HMO without such approval. Coordination of all Verification Form (Forms HtO27 and HLO27-A-C) and
specialty care is the responsibility of the client's primary that the date of birth on the form indicates the client is
care provider. The primary care provider must be notified younger ùhan 2L years of age and no limitations are
by the dentisl and/ or the HMO of the planned seruices. indicated.
Dentists providing sedation/anesthesia services must . Prior authorization is issued to the requesting provider
have the appropriate current permit from the TSBDE for only and is not transferable to another provider. lf the
the level of sedation/anesthesia provided. client changes providers or if the provider stops
The dental provider must be in compliance w¡th the guide- practicing dentistry in the Texas Medicaid Program for
lines detailed in "Criteria for Dental Therapy Under whatever reason, a new prior authorization must be
General Anesthesia" on page 19-33. requested (see "Transfer of Orthodontic Services" on
page 19-38).
Note: Post-treatment authorization will not be approved
for codes that require mandatory prior authorization. The following procedure codes, policies, and limitations
are applied to the processing and payment of orthodontic
services under THSteps dental services:
19.18 Orthodontic Services . Procedure code D8660 is allowed when:
(THSteps) . The client is referred to an orthodontist for a determi-
nation of whether orthodont¡c services are indicated
Orthodontic services for cosmetic purposes only are not a
and to determine the appropriate time to initiate
benefit of the Texas Medicaid Program. Orthodontic
such services.
seryices are limited to the treatment of severe handi-
capping malocclusion and other special medically . The client is referred to an orthodontist and elects to
necessary circumstances as outlined in Benefits and receive services from another orthodontic provider
Limitations below. because of justifiable reasons.
. Repeat visits at different age levels are requlred to
determine the appropriate time to initiate
19.18.1 Benefits and Limitations orthodontic treatme nt.
Orthodontic services include the following: . Procedure code D8680 is payable for one retainer per
. Correction of severe handicapping malocclusion as arch, per lifetime, and may be replaced once because
measured on the Handicapping Labiolingual Deviation of loss or breakage (prior authorization is required).
(HLD) lndex. Refer to page L9-42 for information on . Procedure code D8670 should be billed only when an
how to score the HLD. A minimum score of 26 points is
adjustment to the appliances is provided and may not
required for full banding approval (only permanent be billed before the date the orthodontic adjustment
dentition cases are considered). was performed. The number of visits for monthly adjust-
Exception: Retained deciduous teeth and cleft palates ments to the appliances is restricted to the number
19-36 CPT only copyright 2o07 Amencan l\¡edical Assocration All rights reserued
Dental
that was authorized ¡n the treatment plan. However, the lf orthodontic treatment is medically indicated, providers
number of monthly visits may be amended with appro- are responsible for obtaining prior authorization for a
priate documentation of medical necessity while the complete orthodontic treatment plan while the client is
client is Medicaid eligible. eligible for Medicaid and THSteps and younger Than 21-
. years of age.
Procedure code D867O is paid only in conjunction with
a history of braces (code D8080), unless special Prior authorization is a condition for reimbursement; ¡t is
circumstances exist. not a guarantee of payment.
. All orthodontic codes and appliances are global fees. Upon receipt of prior authorization of complete treatment
. plans, provlders are to adv¡se clients that they will be able
Separate fees for adjustments to retainers are not
payable.
to receive the approved treatment services (e.9.
orthodontic adjustments, bracket replacements and
. The appropriate code should be billed for those appli- retainers), even if they lose Medicaid eligibility or reach
ances required as part of the treatment of cleft palate 2t years of age. Approved ofthodontic treatment must be
cases. initiated before the loss of Medicaid eligibility and
Special orthodontic appliances may also þe used with full completed within 36 months of the authorization date.
banding and crossbite therapy w¡th approval by the TMHP Note: Providers must submit all orthodontic seruices for
Dental Director. Medicaid Managed Care cl¡ents follow¡ng, these guide-
. Procedure codes D5951, D5952, D5953, D5954, lines. STAR and STAR+PLUS are not responsible for
D5955, D5958, D5959, and D5960 are to be used as orthodontic services.
applicable with documentation of medical necessity. Requests for orthodontic services must be accompanied
Otherwise, use the appropriate special orthodontic by all the following documentation:
appliance code. . An orthodontic treatment plan. The treatment plan
. Full banding is allowed on permanent dentltion only, must include all procedures required to complete full
and treatment should be accomplished in one stage treatment (such as, extractions, orthognathic surgery,
and is allowed once per lifetime. upper and lower appliance, monthly adjustments, antic-
Exception: Cases of mixed dentition when the treatment ipated bracket replacements, appliance removal if
plan includes extract¡ons of remaining primary teeth or indicated, spec¡al orthodontic appliances, etc.). The
cleft palate. treatment plan should incorporate only the minimal
number of appliances required to properly treat the
. Crossbite therapy is allowed for primary, mixed, or case. Requests for multiple appliances to treat an
permanent dentition. individual arch are reviewed for duplication of purpose.
. Providers must not requestcrossbite correctlon (limited . Cephalometric radiograph with tracing models
orthodontics) for a mixed dentition client when there is
a need for full banding in the adult teeth. Crossbite
. Completed and scored HLD sheet with diagnosis of
therapy is an inclusive charge for treating the crossbite Angle class (26 points required for approval of non-cleft
to completion, and additional reimbursement is not palate cases).
provided for adjustments or ma¡ntenance. . Facial photographs.
. lf a case is not approved, the dentist may file a claim . Full series of radiographs or a panoramic radiograph;
for payment of the diagnostic work-up necessary to diagnostic-quality films are required (copies are
obtain the authorization using procedure codes D0330, accepted and radiographs will not be returned to the
D0340, D0350, and D0470. The dentist may receive provider).
payment under these procedure codes for no more than . Any additional pertinent information as determined by
two cases out of every ten cases denied. The dent¡st
the dentist or requested by TMHP's Dental Director
should determine if the client's condition meets Requests for crossbite therapy require properly
orthodontic benefit criteria before performing a
trimmed models to be retained in the office and must
diagnostic work-up.
demonstrate the following criteria:
. Procedure codes D8080, D8050, and D8060, are . Posterior teeth. Not end to end, but buccal cusp of
limited to one per lifetime.
upperteeth should be lingual to buccal cusp oflower
teeth.
L9.L8.2 Mandatory Prior Authorizat¡on . Anter¡or teeth. The incisal edge of upper should be
lingual to the incisal of the opposing arch.
Prior authorization is required for all THSteps orthodontic
services except for procedure code D8660. The prior The dentist should be certain that radiographs, photo-
authorization request must contain the date of service graphs, and other information are properly packaged to
thatthe orthodontic records were produced. lf the request avoid damage. TMHP is not responsible for lost or
is approved, the date that the records were produced is damaged materials.
considered to be the date on which orthodontic treatment
beg¡ns.
CPT only copyr¡ght 2007 Amer¡can Medical Assæ¡aliø All rights reseryed L9-37
Section 19
19.18.3 Gompletion of Treatment Plan sheet, nor does the client have to meet the HLD lndex of
26 points. However, a complete plan of treatment ¡s
lf a client reaches 2tyears of age or loses Medicaid eligi-
required.
bility before the authorized orthodont¡c treatment is
completed, reimbursement is provided to complete the Note: Medicaid clients who initiate orthodontic services
orthodontic treatment that was authorized and initiated privately (e.g. pay out of pocket for the orthodont¡c workup
whi le the cl ient was younger tha n 2t years of age, el¡gible and,/or initial band¡ng, etc.) while Medicaid eligible due to
for Medicaid and THSteps, and completed within not meet¡ng the HLD index 26-points, are not eligible to
36 months. Any orthodontic-related service requested have their orthodontic services transferred to and
(e.g., extractions or surgeries) must be completed before reimbursed by Medicaid.
the loss of client eligibility. Services cannot be added or To request prior authorization to complete the orthodontic
approved after Medicaid/THSteps eligibility has expired. treatment initiated by another provider, complete a
THSteps Dental Mandatory Prior Authorization Request
Form and send it with the complete plan of treatment and
L9.L8.4 Premature Removal of Appliances appropriate documentation for orthodontic seryices
The overall fee for orthodontic treatment (D8080) and/or crossbite therapy to the TMHP Dental Director at
includes the removal of orthodontic brackets and/or the following address:
treatment appliances. Procedure code D7997 may be Texas Medicaid & Healthcare Partnership
used only when the appliances were placed by a different THSteps and ICF-MR Dental Authorization and lnformation
provider with an unaffiliated practice (not a partner or
PO Box 2O29t7
office-sharing arrangement) and one of the following Austin, ÎX 74720-29]-7
conditions exist:
. There is documentation of a lack of cooperation from
the client. 19.18.6 Comprehens¡ve Orthodontic
. The client requests premature removal and a release Treatment
form has been signed by the parent, Suardian, or client Comprehensive orthodontic services (procedure code
if he is at least 18 years of age. D8080) are restricted to cl¡ents who are 12 years of age
Providers must keep a copy of the release form on file and and older or clients who have exfoliated all primary
are responsible for this documentation during a review dentition.
process. National procedure codes do not allow for any work-in-
progress or partial billing by separating the three
orthodontic components: diagnostic work-up, orthodontic
19.18.5 Transfer of Orthodontic Services appliance (upper), or orthodontic appliance (lower).
Prior authorization issued to a dental provider for When b¡ll¡ng for comprehensive orthodontic treatment,
orthodontic services is not transferable to another dental D8080, three local codes must be submitted as remarks
provider. The new provider must submit to TMHP a new codes along with code D8080. Local codes (Z2OO9,
prior authorization request ¡n order to be approved to Dia gnostic work-u p a p proved, Z2O L1-, O rthodontic
complete the orthodontic treatment initiated by the appliance, upper, or 22012, Orthodontic appliance, lower)
original provider. are placed in the Remarks Code field on electronic claims
The following supporting documentation must accompany or Block 35 on paper claims.
the new request for orthodontia services and must include Note: lf the remarks code and procedure code D8O8O are
the date of service the orthodontic records were not submitted, the claÌm will be denied.
produced:
Each remarks code pays the correct reimbursement rate
. All of the documentation as required for the original which, when combined, totals the maximum payment of
provider. $775. D8080 must be billed on three separate details,
. The reason the client left the previous provider, if with the appropriate remarks code, even if billing for the
known. work-up and full band¡ng. Billing only one detail for a total
of $775 will not be accepted.
. An explanation of the treatment status.
Example 1: A client is approved for full banding, but after
. A compete treatment plan addressing all procedures for the initial work-up, the client discontinues treatment. This
which authorization is being requested (such as the provider would bill the national code D8080 and place the
number of monthly adjustments or retainers required to local code Z2OO9, D¡agnostic work-up approved, in the
complete the case). Remarks,/comment field. The claim would pay $175.
. A full diagnostic work-up (D8080) with an HLD lndex. Example 2: A client is approved for full banding. The
The score of 26 points will be modified according to any provider continues treatment and places the maxillary
progress achieved.
bands. The provider would bill the national procedure code
Exception:'The prior authorization requests for clients D8080 and place the local code 72OO9, Diagnostic work-
who ¡nitiate orthodontic services before becoming el¡g¡ble up approved, and Z2OII, Maxillary bands, in the
for Medicaid do not require models or the HLD score Remarks,/comment field. The claim would pay $475.
19-38 CPT only copyright 2007 American Medical Assocjation A¡l rights reseryed
Dental
All electronic claims for D8080 must have the appropriate remarks code associated with the procedure
code.
Providers should adhere to the following guidelines for electronic claim submission so that TMHP can
accurately apply the correct remarks code to the appropriate claim detail.
A Diagnostic Procedure Code (DPC) remarks code must be submitted, only once, ¡n the first three bytes
ofthe NTE02 at the 2400 loop.
Example L= For a claim with one detail, submitted with procedure code D8080 and remarks code
Z2OO9, enterthe information as follows: DPCZ2009. The total billed would be $175.
Exampfe 2z For a claim with two details, where details one and two are procedure code D8080 and the
remarks codes are Z2OO9 and Z2OII, enter the information as follows: DPCZ2OO9Z2011. The total
billed would be $475.
Example 3: For a claim with three details, where all three details are submitted separately with
procedure code D8080, enter the remarks code þased on the order of the claim detail as follows:
DPC220092201,122072. The total billed would be $775.
This method ensures accurate and appropriate payment for services rendered and addresses the need
for paftial billing.
L9.L8.7 Orthodontic Procedure Codes and Fee Schedule
When submitting claims for orthodontic procedures, use the following procedure codes
Procedure Code Limitations Maximum Fee
Orthodontic Services
D0330*, When requested orthodontic cases are submitted for authorization $100.00
D0340*, and denied, two out of ten denials will be paid. These four
DO350x, and procedure codes, when billed together for denied cases, replace
D0470* local procedure code Z2OLO.
D7280 A1_-20 $62.50
D7997* Replaces Z2OL6. Not payable to the dentist who placed the $50.00
appliance. lncludes removal of arch bar and premature removal of
braces. A1--20
D8050* Replaces Z2Ot8 and 8110D. Limited to one per lifetime. $340.00
D8060* Replaces Z2OLa and 8120D. Limited to one per lifetime. $340.00
D8080* Replaces Z2OO9, Z2O1-!, and Z2Qt2. Limited to one per lifetime $775.00
Minor Treatment to Control Harmful Habits
D8210* See separate taþle for associated remarks field code See separate
table
D8220* See separate table for associated remarks field code See separate
table
D8660* Replaces Z2OO8. $15.00
D8670* Replaces Z2OI3 $68.10
D8680* Replaces Z2OI4 and 22075. $100.00
D8690* Bracket replacement. $20.00
D8691 Not considered medically necessary NC
D8692 Limited to one service per arch per lifetime for each retainer NC
D8999 Manually
priced
*
= Services payable to an FQHC for a client encounter
CP-f only copyr¡ght 2007 American Med¡cal Assæ¡at¡on All rights reseryed 19-39
Section 19
19.19 Special Orthodontic Appliances
As with all orthodontic services, all removable or fixed special orthodontic applicances must be prior
authorized. The prior authorization request must include both the national code and remarks code.
However, prior authorization requests may omit the DPC prefix to the e¡ght-digit remarks code.
All removable or fixed special orthodontic appliances must be billed with national procedure code
D82\O or D822O. Dental models must be submitted when requesting prior authorization of a thumb-
sucking or tongue thrust appliance. To ensure appropriate claims processing, the DPC remarks code
(local procedure code) reflecting the specific seruice is also required. The appropriate remarks codes
must be entered on the authorization request form. Failure to follow the following steps will cause the
claims to deny. Failure to enterthe DPC remarks code and the appropriate procedure code will not result
in claim denial; however, manual intervention is required to process the claim, which may result in a
delay of payment.
For paper claim submissions, providers must enter the local procedure code in Block 35 (Remarks) of
the 2006 ADA claim form.
For electronic submissions, providers enter the DPC remarks code in the Comments field to ensure
correct authorization, accurate records, and reimbursement.
For electronic submissions other than TexMedConnect or TDHconnect software submissions, providers
must follow the steps below to ensure TMHP accurately applies the correct local procedure code to the
appropriate claim detail:
t) The DPC prefix must be submitted, only once, in the first three bytes of the NTEO2 at the 2400
loop.
2) ln bytes 4-8, providers must submit the remark code (local procedure code) based on the order of
the claim detail. Do not enter any spaces or punctuat¡on between remark codes, unless to
designate the detail is not billed with D8210 or D822O.
Example: For a claim w¡th three details, where details one and three are submitted wìth procedure code
D8270 and detail two rs not, enter the followin! information ¡n the NTE02 at the 24OO loop: DPC7074D
7046D. (The space shows that detail two needs no local code.) lf all details require a local code, enter
DPC, no spaces, and the appropriate local codes.
To submit using TexMedconnect or TDHconnect software, providers must enter the local code into the
Remarks Code field, located underthe details header. The Remarks Code field is the field directly after
the Procedure Code field. TexMedConnect and TDHconnect software submitters are not required to
manually enter the DPC prefix as it is placed in the appropriate field on the TexMedConnect or
TDHconnect electronic claim.
The following table identifies the appropriate DPC remarks codes to use when requesting authorization
or billing for procedure code D8210 or D822O:
Procedure Remarks Maximum
Code Gode Remarks Code Desctiption Fee
Special Orthodontic Appliances
D8220* DPC1000D Appliance with horizontal projections $250
D8220* DPC1001D Appliance with recurved springs $250
D8220" DPClOO2D Arch wires for crossbite correction (for total treatment) $595
D8220* DPC1003D Banded maxillary expansion appliance $375
D8270* DPC1004D Bite plate/bite plane $100
D8210* DPC1005D Bionator $1oo
D8210* DPC1006D Bite block $250
D82LO* DPC1007D Bite-plate with push springs $250
D8220* DPC1008D Bonded expansion device $225
D82LO* DPC1010D Chateau appliance (face mask, palatal exp and hawley) $300
D82tO* DPC1011D Coffin spring appliance $275
D8220* DPCLOL2D Crib $10o
*
= Services payable to an FQHC for a client encounter
19-40 cPT only copyright 2007 Amer¡can ¡.4edical Assoc¡at¡on All r¡ghts reseryed
Dental
Procedure Remarks Maximum
Code Code Remarks Gode Description Fee
D8210* DPC1O13D Dental obturator, definitive (obturator) $250
D8210* DPC1O14D Dental obturator, surg¡cal (obturator, surgical stayplate, $250
immediate tem porary obturator)
D8220'É DPC1015D Dista lizing appliance with springs $250
D8220'( DPC1016D Expansion device $375
D8210* DPC1017D Face mask (protraction mask) $350
D8220* DPC1O18D Fixed expansion appliance $375
D8220* DPC1019D Fixed lingual arch $225
D8220* DPC1020D Fixed mandibular holding arch $100
D8220" DPCLO2AD Fixed rapid palatal expander $375
D82LO* DPCtO22D Frankel appliance $100
D8210* DPC1023D Functional appliance for reduction of anterior openbite and $375
crossbite
D82aO* DPC7024D Headgear (face bow) $150
D8220" DPC1025D Herbst appliance (fixed or removable) $250
D8220* DPC1026D lnter-occlusal cast cap surgical splints $375
D8210* DPC].O2TD lntrusion arch $100
D8220* DPC1028D Jasper jumpers $100
D8220* DPC1029D Lingual appliance with hooks $100
D8220* DPC1030D Mandibular anterior bridge $175
D8220+ DPC1031D Mandibular bihelix (similar to a quad helix for mandibular $10o
expansion to attempt nonextraction treatment)
D8210* DPC1032D Mandibular lip bumper $100
D8220" DPC1O36D Mandibular lingual 6x6 arch wire $100
D82rO* DPC1037D Mandibular removable expander with bite plane (crozat) $275
D82tO+ DPC1038D Mandibular ricketts rest posit¡on splint $375
D8210* DPC1039D Mandibular splint $225
D8210* DPClO4OD Maxillary anterior bridge $175
D8210* DPC1041D Maxillary bite-opening appliance w¡th anterior springs $100
D8220" DPCLO42D Maxillary l¡ngual arch with spurs $1oo
D8220" DPC1O43D Maxillary and mandibular distalizing appliance $1oo
D822O'r DPC1044D Maxillary quad helix with finger springs $325
D8220* DPC1045D Maxillary and mandibular retainer with pontics $175
D8210* DPC1046D Maxillary Schwarz $250
D82tO* DPCAO TD Maxillary splint $225
D82tO* DPC1048D Mobile intraoral Arch-Mia (similar to a Bihelix for nonex- $100
traction treatment)
D8220* DPC1049D Modified quad helix appliance $275
D8220* DPC1050D Modified quad helix appliance (with appliance) $275
D8220* DPC1051D Nance appliance $10o
D8220* DPC1052D Nasal stent $250
D82LO* DPC1053D Occlusal orthotic device $175
*
= Services payable to an FQHC for a client encounter
CPf only copynght 2007 American lvledical Assæiat¡on All r¡ghts reseryed L94L
Section 19
Procedure Remarks Maximum
Code Code Remarks Code Descliption Fee
D82LO* DPC1054D Orthopedic appllance $250
D8210* DPC1O55D Other mand¡bular utilities $100
D8210* DPC1O56D Other maxillary utilities $100
D8220* DPC1057D Palatal bar $225
D8210'r. DPC1058D Post-surg¡cal retainer $125
D8220* DPC1059D Quad helix appliance held with transpalatal arch horizontal $275
projections
D8220* DPC1060D Quad helix maintainer $275
D8220* DPC1061D Rapid palatal expander (RPE), such as quad Helix, Haas, or $350
Menne
D8210* DPC1062D Removable bite plate $100
D82LO* DPC1063D Removable mandibular retainer $100
D8210* DPC1O64D Removable maxillary retainer $100
D8210* DPC1065D Removable prosthesis $175
D8210* DPC1066D Sagittal appliance 2 way $250
D8210* DPC1067D Sagittal appliance 3 way $350
D8220* DPC1068D Stapled palatal expansion appliance $375
08210* DPC1069D Surgical arch wires $250
D82LO" DPC1070D Surgical splints (surgical stenti/wafer) $250
D8210* DPC1071D Surgical stabilizing a ppliance $250
D8220* DPC]-OT2D Thumbsucking appliance, requires submission of models $175
D8210* DPC1073D Tongue thrust appliance, requires submission of models $1oo
D82LO* DPC1074D Tooth positioner (full maxillary and mandibular) $325
D8210* DPC1O75D Tooth positioner with arch $10o
D8220" DPC1076D Transpalatal arch $100
D8220* DPQ|OTTD Two bands with transpalatal arch and horizontal projections $175
forward
D8220* DPC1078D W-appliance $275
*
= Services payable to an FQHC for a client encountel.
L9.2O How to Score the Handicapping Labiolingual Deviation (HLD)
lndex
The orthodontic provider must complete and sign the diagnosis (Angle class)'
Gleft Palate
Submita cleft palate case inthe mixed dentition only if itcan be justified in a narrative whythere should
be treatment before the client is in the full dentition.
Note: lntermittent treatment requests may exceed the allowable 26 reimbursable treatment v¡s¡ts.
Severe Traumatic Deviations
Refers to facial accidents only. Points cannot be awarded for congen¡tal deformity. Severe traumatic
deviations do not include traumatic occlusions for crossbites.
Overjet in Millimeters
Score the case exactly as measured, then subtract 2 mm (considered the norm), and enter the
difference as the score.
L942 CPT only copyrght 2007 American Medrcal Assciat¡on All rights reseryed
Append¡x H
Append¡x I
R49 – tadlock spreadsheet
Ectopic score
Ectopic score
Antoine HLD
Tadlock HLD
# ANTOINE SCORES - BY TOOTH
Upper Lower
3 2 1 1 2 3 3 2 1 1 2 3
1 1 1 1 1 1 1 1 1 26 24 0 0
2 1 1 1 1 1 1 1 1 32 24 4 0
3 1 1 1 1 1 1 1 1 26 24 2 0
4 1 1 1 1 1 1 1 1 1 1 1 1 38 36 11 6
5 1 1 1 1 1 1 1 1 27 24 9 0
6 1 1 1 1 1 1 1 1 27 24 1 0
7 1 1 1 1 1 1 1 1 32 24 19 0
8 1 1 1 1 1 1 1 1 35 24 5 0
9 1 1 1 1 1 1 1 1 27 24 10 0
10 0 0 6 0
11 1 1 1 1 1 1 1 1 27 24 5 0
12 1 1 1 1 1 1 1 1 1 1 1 1 36 36 7 3
13 1 1 1 1 1 1 1 1 1 1 1 1 36 36 0 0
14 1 1 1 1 1 1 1 1 1 1 33 30 2 0
15 1 1 1 1 1 1 1 1 1 1 1 1 55 36 28 0
16 1 1 1 1 1 1 1 1 1 1 36 30 13 0
17 1 1 1 1 1 1 1 1 1 1 1 1 39 36 3 0
18 1 1 1 1 1 1 1 1 28 24 10 0
19 1 1 1 1 1 1 1 1 1 1 1 1 40 36 16 0
20 1 1 1 1 1 1 1 1 1 29 27 7 0
21 1 1 1 1 1 1 1 1 30 24 9 0
22 1 1 1 1 1 1 1 1 28 24 3 0
23 1 1 1 1 1 1 1 1 28 24 9 0
24 1 1 1 1 1 1 1 1 29 24 1 0
25 1 1 1 1 1 1 1 1 27 24 1 0
26 1 1 1 1 1 1 1 31 21 12 0
27 1 1 1 1 1 1 1 1 29 24 3 0
28 1 1 1 1 1 1 1 1 28 24 0 0
29 1 1 1 1 1 1 1 1 29 24 5 0
30 1 1 1 1 1 1 1 1 28 24 3 0
31 1 1 1 1 1 1 1 1 26 24 5 0
32 1 1 1 1 1 1 1 1 1 1 1 1 44 36 15 0
33 1 1 1 1 1 1 1 1 1 1 1 1 48 36 12 0
34 1 1 1 1 1 1 1 1 1 30 27 7 0
35 1 1 1 1 1 1 1 1 31 24 6 0
36 1 1 1 1 1 1 1 1 29 24 10 0
37 1 1 1 1 1 1 1 29 21 15 6
38 1 1 1 1 1 1 26 18 4 0
39 1 1 1 1 1 1 1 1 27 24 7 0
40 1 1 1 1 1 1 1 1 1 1 33 30 4 0
41 1 1 1 1 1 1 1 1 30 24 7 0
42 1 1 1 1 1 1 1 1 28 24 12 6
43 1 1 1 1 1 1 1 1 27 24 1 3
44 11 0
45 1 1 1 1 1 1 1 1 1 31 27 0 0
46 1 1 1 1 1 1 1 1 1 1 1 1 36 36 4 3
47 1 1 1 1 1 1 1 1 35 24 8 0
48 1 1 1 1 1 1 1 1 32 24 7 0
49 1 1 1 1 1 1 1 1 1 1 34 30 7 0
50 1 1 1 1 1 1 1 1 27 24 12 0
51 4 0
52 1 1 1 1 1 1 29 18 3 0
53 1 0
54 1 1 1 1 1 1 1 1 1 1 1 1 36 36 1 0
55 1 1 1 1 1 1 1 1 1 1 1 1 39 36 7 3
56 1 1 1 1 1 1 1 1 30 24 6 0
57 1 1 1 1 1 1 1 1 35 24 4 0
58 1 1 1 1 1 1 1 1 1 1 1 1 36 36 11 0
59 1 1 1 1 1 1 1 1 1 1 30 30 0 0
60 1 1 1 1 1 1 1 1 30 24 6 0
61 1 1 1 1 1 1 1 1 1 1 1 1 36 36 11 6
62 1 1 1 1 1 1 1 1 1 1 1 1 36 36 14 0
63 1 1 1 1 1 1 26 18 10 0
R49 - tadlock spreadsheet.Revised.xlsx Page 1
Append¡ J
SOAH DOCKET NO. XXX-XX-XXXX
HHSC-OIG CASE NO.: P2011131652384891
ANTOINE DENTAL CENTER, § BEFORE THE STATE OFFICE
Petitioner §
§
v. §OF
§
§
TEXAS HEALTH & HUMAN § ADMINISTRATIVE HEARINGS
SERVICES COMMISSION, OFFICE §
OF INSPECTOR GENERAL, §
Respondent §
§
HHSC-OIG’s PROFFER OF REBUTTAL
TESTIMONY FROM DR. LINDA ALTENHOFF
TO THE HONORABLE ADMINISTRATIVE LAW JUDGES:
COMES NOW the Texas Health and Human Services Commission, Office of
Inspector General (“HHSC-OIG”), and requests the ability to recall Dr. Linda Altenhoff
to offer rebuttal testimony. HHSC-OIG offers the following proffer of expected
testimony from Dr. Altenhoff:
PROFFER
Q: Dr. Altenhoff, you are the same Linda Altenhoff who testified on day one of this
hearing, correct?
A: lam.
Q: Have you been in attendance during all of the testimony given by the various
witnesses?
A: Ihave been.
Q: Specifically, did you hear the testimony of Dr. Orr and Dr. Kanaan?
A: Idid.
1
000695
Q: Did you hear their testimony regarding the meaning of ectopic eruption as used by
Texas Medicaid?
A: Idid.
Q: Dr. Altenhoff, did Medicaid intend, at any time, for the term “ectopic eruption” to
have a different meaning when used in the evaluation of Medicaid patients than is
generally understood in the practice of dentistry?
A: No.
Q: Were dentists expected to employ the training and education they received as
dentists in applying the terms used in the Provider Manual?
A: Yes.
PRAYER
For these reasons, HHSC-OIG prays to be allowed to recall Dr. Linda Altenhoff
for limited rebuttal testimony in keeping with the above proffer.
Respectfully submitted,
GREG ABBOTT
Attorney General of Texas
DANIEL T. lODGE
First Assistant Attorney General
JoHN B. SCOTT
Deputy First Assistant Attorney General
RAYMc(pJC. WINTER
State Bar No. 21791950
Chief, Civil Medicaid Fraud Division
(512) 936-1709
MARGARET MOORE
State Bar No. 14360050
2
000696
Deputy Chief, Civil Medicaid Fraud Division
(512) 936-1319 direct dial
Assistant Attorneys General
P.O. Box 12548
Austin, Texas 78711-2548
(512) 499-0712 fax
Va aoc’e
Dan Hargrove
State Bar No. 00790822
WATERS & KRAUS, LLP
3219 McKinney Avenue
Dallas, Texas 75204
(214) 357-6244 Telephone
(214) 357-7252 Facsimile
m
James Moriarty
State Bar No. 14459000
MORIARTY LEYENDECKER, PC
4203 Montrose Blvd, Suite 150
Houston, TX 77006
(713) 528-0700 Telephone
3
000697