Sec. 533.00281. UTILIZATION REVIEW FOR STAR + PLUS MEDICAID MANAGED CARE ORGANIZATIONS. (a) The commission's office of contract management shall establish an annual utilization review process for 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, except that the review process must include a thorough investigation of each managed care organization's procedures for determining whether a recipient should be enrolled in the STAR + PLUS home and community-based services and supports (HCBS) 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 managed care organization participating in the STAR + PLUS Medicaid managed care program; or
(2) only the managed care organizations that, using a risk-based assessment process, the office determines have a higher likelihood of inappropriate client placement in the STAR + PLUS home and community-based services and supports (HCBS) program.
(c) Notwithstanding Subsection (b), during the state fiscal biennium ending August 31, 2015, the office of contract management shall use the utilization review process to review every managed care organization participating in the STAR + PLUS Medicaid managed care program. This subsection expires September 1, 2016.
(d) 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 not later than December 1 of each year. 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 managed care organization; and
(3) extrapolate those findings and make recommendations for improving the efficiency of the program.
(e) If a utilization review conducted under this section results in a determination to recoup money from a managed care organization, a service provider who contracts with the managed care organization may not be held liable for the good faith provision of services based on an authorization from the managed care organization.
Added by Acts 2013, 83rd Leg., R.S., Ch. 76 (S.B. 348), Sec. 1, eff. May 18, 2013.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.220, eff. April 2, 2015.
Section: Previous 533.00255 533.002551 533.00256 533.00257 533.0026 533.0027 533.0028 533.00281 533.0029 533.003 533.004 533.005 533.0051 533.00511 533.0052 NextLast modified: September 28, 2016