26 Tex. Admin. Code § 277.91 - Utilization Review
(a) HHSC conducts
utilization review of a service delivery plan and supporting documentation at
any time to:
(1) determine the
appropriateness of services;
(2)
validate a service provision; or
(3) evaluate the quality of
services.
(b) A provider,
consumer directed services employer, and FMSA must submit documentation
supporting the service delivery plan to HHSC as requested by HHSC.
(c) If HHSC determines that one or more of
the tasks specified in a service delivery plan do not meet the requirements
described in Subchapter D of this chapter (relating to Service Plan
Development) or Subchapter E of this chapter (relating to Service
Requirements), HHSC denies or reduces the hours or tasks, modifies the service
delivery plan effective from the date of the utilization review, and sends
written notification of the denial or reduction to the individual and
provider.
(d) In addition to the
utilization review conducted in accordance with subsection (a) of this section,
HHSC may conduct utilization reviews of providers and services based on
utilization patterns and trends.
Notes
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