Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354 - MEDICAID HEALTH SERVICES
Subchapter A - PURCHASED HEALTH SERVICES
Division 11 - GENERAL ADMINISTRATION
Section 354.1159 - Utilization Review

Universal Citation: 1 TX Admin Code ยง 354.1159

Current through Reg. 49, No. 38; September 20, 2024

The health insuring agent performs the following utilization review functions:

(1) studies conducted by the professional and paraprofessional staff to develop, test, revise, implement, and monitor prepayment and postpayment screens relating to medical necessity, appropriateness of care, setting in which service was delivered, and potential fraud;

(2) consultation with professional associations in defining criteria;

(3) publication and distribution of prepayment criteria to appropriate providers;

(4) review of suspended claims to determine medical necessity; review and resolution of claims suspended by the system for professional or paraprofessional determination of medical necessity;

(5) provider communications:

(A) seminars and workshops to the extent that such meetings relate to utilization review;

(B) visits to individual physicians, doctors, hospitals, etc., to discuss patterns of practice, billing practices as they directly relate to utilization and recovery of any funds.

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