Common use of Utilization Review Clause in Contracts

Utilization Review. The use of utilization and review activities ensures program fiscal integrity, addresses the state mandate requiring program funds be spent only as allowed under state laws and regulations, and ensures that services are based on medical necessity and efficacy of services provided. Records are chosen for review through a random sample or if billing issues are noted by CRS field staff. Review of individual records with services and billing occur from the point of entry into the CRS program until after the individual ends treatment and may include prospective, concurrent, and retrospective review activities. Additionally, Contractors are required to participate in cost reporting and cost surveys performed by the HHSC Rate Analysis Department.

Utilization Review. The use of utilization and review activities ensures program fiscal integrity, addresses the state mandate requiring program funds be spent only as allowed under state laws and regulations, and ensures ensure that services are based on medical necessity and efficacy of services provided. Records are chosen for review through a random sample or if billing issues are noted by CRS field staff. Review of individual records with services and billing occur from the point of entry into the CRS program until after the individual ends ends/concludes treatment and may include prospective, concurrent, and retrospective review activities. Additionally, Contractors are required to participate in cost reporting and cost surveys performed by the HHSC Rate Analysis Department.