5200 Utilization Review Report to the Regions

Revision 24-3; Effective July 1, 2024

Concurrent Utilization Review (UR) may have findings or no findings to report to the region.

If any findings or information need to be relayed to the region, the UR manager emails the complete UR tool to the regional director (RD) or their designee. Once the UR tool indicating a required action in the Findings/Summary section of the UR tool is received, the region can either:

  • file an exception within five business days of receipt of the UR tool (review Section 5500, Utilization Review Exception Process, for guidelines); or
  • contact the assigned caseworker and require the UR recommended changes be implemented.

If there are no findings, the UR nurse contacts the caseworker by phone or email to inform the caseworker there were no findings. The UR tool will not be forwarded to the region, and no documentation is required in the case record for a concurrent review with no findings. 

5210 Other Utilization Review Reporting Processes

Revision 24-3; Effective July 1, 2024

The Utilization Review (UR) nurse manager informs the regional director (RD) within one HHSC business day if the following situations are identified during any UR:

  • immediate threat to health or safety or medical emergency involving the person;
  • risk or threat of danger to a person;
  • abuse, neglect, or exploitation of a person;
  • violation of individual rights, problem with quality of services, potential fraud, or potential threat to health and safety; and
  • fraud, waste, and abuse of services. If indicated, the RD will make a referral to the Office of Inspector General through established procedures and report the referral to the UR manager.