Texas Government Code 540.0755 – 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.
Terms Used In Texas Government Code 540.0755
- Contract: A legal written agreement that becomes binding when signed.
- Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
- Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
- Year: means 12 consecutive months. See Texas Government Code 311.005
(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.
Text of section effective on April 01, 2025