1. (a) The purpose of a utilization review and a quality assurance review is:

   1. (1) to ensure program fiscal integrity;
   2. (2) to address the federal mandate requiring program funds be spent only as allowed under federal and state laws and regulations; and
   3. (3) to ensure that a case manager provided Case Management for Children and Pregnant Women services to a client within the scope of the client's Service Plan.
2. (b) HHSC conducts quality assurance and utilization reviews of all active providers to monitor claims, the quality of case management services, and compliance with Case Management for Children and Pregnant Women rule and policy.
3. (c) A provider must cooperate with the quality assurance and utilization reviews. A provider will be given notification of upcoming reviews in accordance with the policies and procedures established by HHSC.
4. (d) If the results of a provider's utilization review or quality assurance review as determined by HHSC, indicates overpayment, HHSC notifies the provider of the overpayment and gives the provider information about how to arrange for repayment.
5. (e) If a provider becomes aware that the provider received an overpayment, the provider must notify the Medicaid claims administrator to arrange for repayment.

Source Note:The provisions of this §257.23 adopted to be effective May 29, 2025, 50 TexReg 3129.