26 Tex. Admin. Code § 256.72 - Dental Utilization Reviews
(a) Purpose. The purpose of dental
utilization reviews is to ensure program fiscal integrity, to address the
federal mandate requiring program funds be spent only as allowed under federal
and state laws and regulations, and to ensure that services are appropriately
provided to clients.
(b) Recoupment
of overpayments. If the results of a utilization review indicate overpayment
for services delivered or that payment was made for services not delivered,
recoupment is required. The appropriate agency or agency designee shall notify
the provider in writing of any overpayment identified and the method of
recoupment to be used.
(c)
Administrative actions and sanctions. Evaluation of a utilization review may
result in one or more of the following administrative actions or sanctions by
the appropriate agency or the agency's designee:
(1) closure of the review with written
notification to the provider;
(2)
discussion and interpretation of the utilization review results with the
provider;
(3) referral to the
appropriate state licensing board or OIG; and
(4) any other remedies authorized by rule,
regulation, statute, or contract.
Notes
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