| (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.
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