Texas Administrative Code
Title 25 - HEALTH SERVICES
Part 1 - DEPARTMENT OF STATE HEALTH SERVICES
Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN
Subchapter C - PROVIDER QUALIFICATIONS AND RESPONSIBILITIES
Section 27.25 - Utilization and Quality Assurance Reviews and Compliance

(a) The purpose of a utilization or quality assurance review 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) During each fiscal year, the department will conduct quality assurance and utilization reviews of all active and inactive providers to monitor claims, quality of case management services and compliance with Case Management for Children and Pregnant Women rule and policy.

(c) Providers must cooperate with the quality assurance and utilization reviews. Providers will be given notification of upcoming reviews in accordance with the department's policies and procedures.

(d) If the results of the utilization or quality assurance review indicate overpayment, the department will notify HHSC of the overpayment and the provider will be given information about how to arrange for repayment.

(e) Providers must voluntarily notify the Medicaid claims administrator to arrange for repayment if they become aware that they received an overpayment.