Reviews of a consumer’s records, services, and billing can occur from the point of entry into the CRS program until after the consumer ends or completes treatment and may include prospective, concurrent and retrospective review activities.
The purpose of a CRS utilization review is to:
- ensure the program fiscal integrity of the provider;
- address the state laws and regulations that program funds be spent only as allowed; and
- ensure that services are provided based on medical necessity and are continued based on their efficacy.
A consumer’s records may be chosen for review through a random sample or based on billing issues noted by CRS program staff members.