| (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. |
