8100, Utilization Review Purpose
Revision 19-1; Effective June 3, 2019
Utilization Review (UR) is a division within the Medicaid Children's Health Insurance Program (CHIP) Services Department of the Texas Health and Human Services Commission (HHSC). UR was created by Senate Bill 348, 83rd Legislature Regular Session, 2013. This bill amended Section 533.00281 of the Texas Government Code to allow HHSC to review utilization of the STAR+PLUS Home and Community Based Services (HCBS) Program. HHSC has extended the scope of UR to include review of STAR Kids Medically Dependent Children Program (MDCP) services as well as state plan services provided in STAR Kids.
STAR Kids managed care organizations (MCOs) must make information including, but not limited to, documents, assessments, notes and authorizations regarding STAR Kids members available upon request from UR. STAR Kids MCOs must participate and make appropriate staff available for reviews conducted by UR upon request from that division.