Provider Alert! Texas Children’s Health Plan Special Investigations Unit and Claims Payment Review Information

Attention: All Providers
Effective Date: October 23, 2020

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan (TCHP) would like to share information with our provider network on two important topics, the Special Investigation Unit and Claims Payment Reviews.

What is the Special Investigations Unit?

Texas Children’s Health Plan’s Special Investigations Unit (SIU) is organized within the Office of General Counsel under the Controls and Compliance Department. The SIU includes staff trained in the performance of fraud waste and abuse (FWA) investigations, medical coding, analytics and medical record reviews. The SIU works to prevent, detect and report potential issues of FWA to the State in accordance with the Texas Administrative Code (“TAC”) § 353.502 and § 370.502.  SIU Audits are utilized to monitor compliance and assist in detecting and identifying Medicaid program violations and possible overpayments related to FWA. Typical reviews involve comparing  services billed to the actual clinical medical records.  Any irregular pattern or trend, missed regulatory requirement, or other identified issue with a provider’s billing, could result in recoupment.  If you have any questions regarding TCHP’s commitment to preventing and detecting FWA or if you suspect potential FWA please call 1-832-828-1320 or e-mail the SIU at TCHPSIU@texaschildrens.org.

TCHP Claims Payment Reviews

Texas Children’s Health Plan (TCHP) is currently subcontracted with SCIO Health Analytics, a third party audit company, to conduct a variety of claims payment audits on its behalf.  SCIO Health Analytics is the business name of SCIO Inspire, Corp. and the parent company of Hospital Audit Locus, Inc. d/b/a National Audit.

SCIO audits include but are not limited to the following:

• Hospital Bill Audits
• DRG /APC Validation
• Itemized Bill Review
• Prepayment Review

TCHP authorizes SCIO Health Analytics to conduct the audits mentioned above on behalf of Texas Children’s Health Plan, as a part of its oversight and monitoring responsibilities, as mandated by Federal and State regulatory guidelines.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers