26 Tex. Admin. Code § 257.23 - Compliance with Utilization Reviews and Quality Assurance Reviews and Overpayments
(a) The purpose of a
utilization review and a quality assurance review is:
(1) to ensure program fiscal
integrity;
(2) to address the
federal mandate requiring program funds be spent only as allowed under federal
and state laws and regulations; and
(3) to ensure that a case manager provided
Case Management for Children and Pregnant Women services to a client within the
scope of the client's Service Plan.
(b) HHSC conducts quality assurance and
utilization reviews of all active providers to monitor claims, the quality of
case management services, and compliance with Case Management for Children and
Pregnant Women rule and policy.
(c)
A provider must cooperate with the quality assurance and utilization reviews. A
provider will be given notification of upcoming reviews in accordance with the
policies and procedures established by HHSC.
(d) If the results of a provider's
utilization review or quality assurance review as determined by HHSC, indicates
overpayment, HHSC notifies the provider of the overpayment and gives the
provider information about how to arrange for repayment.
(e) If a provider becomes aware that the
provider received an overpayment, the provider must notify the Medicaid claims
administrator to arrange for repayment.
Notes
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