Revision 14-1; Effective September 1, 2014    

 

 

The Texas Legislature, through the General Appropriations Act, mandates the use of utilization management and review practices, as necessary, to ensure the appropriate scope and level of services are provided to individuals and to ensure compliance with federal cost-effectiveness requirements.

 

5100 Utilization Review (UR) Program Description

Revision 14-1; September 1, 2014

 

Every two years, the Texas Legislature, through the General Appropriations Act, mandates the use of utilization management and UR practices, as necessary, to ensure the:

  • appropriate scope and level of services are provided to individuals receiving services in Medicaid 1915(c) waivers administered by the agency; and
  • compliance with the cost-effectiveness requirement of the Centers for Medicare and Medicaid Services (CMS).

The focus of DADS UR is based on the direction provided in the General Appropriations Act.

 

5110 Case Selection Processes

Revision 14-1; September 1, 2014

 

Each fiscal year, DADS selects a statistically valid statewide random sample of individual cases, based on the program total enrollment and proportionate to the number of people serviced in a region. The unit of sample is the individual who is actively enrolled in the program.

Based on this selection process, DADS performs a review of selected individuals based on the current Individual Plan of Care.

 

5111 Review Processes

Revision 14-1; September 1, 2014

 

Utilization Review (UR) procedures may include review of DADS case files and contracted provider documents, a face-to-face assessment of the individual and his living environment, and interviews with staff from DADS, the Home and Community Support Services Agency (HCSSA), agency caregivers and other MDCP contracted providers. The UR nurse may request files or documents from the HCSSA or other MDCP contracted provider to include service-related documentation, such as plans of care, service records, training records, time sheets, minor home modification or adaptive aid documentation. The UR nurse will provide the time frame by which the HCSSA and other contracted providers need to submit the information.

 

5112 Communication of UR Findings

Revision 14-1; September 1, 2014

 

The Utilization Review (UR) findings may be in agreement with the Individual Plan of Care (IPC), as written, or the UR staff findings may indicate a need for a reduction, denial, termination, increase or addition of a service or services. The UR nurse discusses the preliminary findings and rationale for the findings with the DADS case manager and Home and Community Support Services Agency (HCSSA), as applicable, to ensure all relevant information is considered. During this discussion, the UR nurse identifies the required time frames for submitting additional input and documentation. After reviewing the additional information, the UR nurse and UR nurse manager finalize the findings.

The UR regional manager submits findings indicating a need to reduce, deny, terminate, increase services or add new services to the Access and Intake, Community Services regional director for processing. Regional UR staff evaluate the findings and, if no formal exception is filed, send the new IPC to the DADS case manager for implementation. The DADS case manager mails the individual a notice of adverse action with a right to appeal for IPC changes resulting in a reduction, denial or termination of services. DADS case managers use existing time frames for reporting IPC changes to the HCSSA. UR findings in agreement with the IPC are tracked by UR for routine reporting, but no further action is taken.

 

5113 Other UR Reporting Requirements

Revision 14-1; September 1, 2014

 

The Utilization Review nurse immediately notifies the Community Services regional director, Consumer Rights and Services, and the Home and Community Support Services Agency if either of the following situations is identified during a review:

  • the immediate threat to the health or safety or medical emergency involving an applicant or individual; or
  • the risk or threat of danger to an applicant or individual.