Texas § GV.540.0755 - UTILIZATION REVIEW

§ GV.540.0755. UTILIZATION REVIEW

UTILIZATION REVIEW; ANNUAL REPORT. (a) The commission's office of contract management shall establish an annual utilization review process for Medicaid managed care organizations participating in the STAR+PLUS Medicaid managed care program. The commission shall determine the topics to be examined in the review process. The review process must include a thorough investigation of each Medicaid managed care organization's procedures for determining whether a recipient should be enrolled in the STAR+PLUS home and community-based services (HCBS) waiver program, including the conduct of functional assessments for that purpose and records relating to those assessments. (b) The office of contract management shall use the utilization review process to review each fiscal year: (1) every Medicaid managed care organization participating in the STAR+PLUS Medicaid managed care program; or (2) only the Medicaid managed care organizations that, using a risk-based assessment process, the office determines have a higher likelihood of inappropriate recipient placement in the STAR+PLUS home and community-based services (HCBS) waiver program. (c) Not later than December 1 of each year and in conjunction with the commission's office of contract management, the commission shall provide a report to the standing committees of the senate and house of representatives with jurisdiction over Medicaid. The report must: (1) summarize the results of the utilization reviews conducted under this section during the preceding fiscal year; (2) provide analysis of errors committed by each reviewed Medicaid managed care organization; and (3) extrapolate those findings and make recommendations for improving the STAR+PLUS Medicaid managed care program's efficiency. (d) If a utilization review conducted under this section results in a determination to recoup money from a Medicaid managed care organization, a service provider who contracts with the organization may not be held liable for providing services in good faith based on the organization's authorization. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611 ), Sec. 1.01, eff. April 1, 2025. SUBCHAPTER Q. DELIVERY OF SERVICES: STAR HEALTH PROGRAM