SECTION 354.1159. Utilization Review

The health insuring agent performs the following utilization review functions:

(1) studies conducted by the professional and paraprofessional staff to develop, test, revise, implement, and monitor prepayment and postpayment screens relating to medical necessity, appropriateness of care, setting in which service was delivered, and potential fraud;

(2) consultation with professional associations in defining criteria;

(3) publication and distribution of prepayment criteria to appropriate providers;

(4) review of suspended claims to determine medical necessity; review and resolution of claims suspended by the system for professional or paraprofessional determination of medical necessity;

(5) provider communications:

(A) seminars and workshops to the extent that such meetings relate to utilization review;

(B) visits to individual physicians, doctors, hospitals, etc., to discuss patterns of practice, billing practices as they directly relate to utilization and recovery of any funds.

Source Note: The provisions of this §354.1159 adopted to be effective May 30, 1977, 2 TexReg 1929; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561