5500, Utilization Review Exception Process

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5500 Utilization Review Exception Process

Revision 17-1; Effective March 15, 2017

If the regional director disagrees with the Utilization Review (UR) recommendation, he will refer the case via email and telephone within five workdays to the manager of the Community Care Services Eligibility (CCSE) unit at state office.

The state office CCSE unit manager will then make a final decision on whether to implement, revise or reverse the UR recommendation. The state office CCSE decision will be made within five workdays of the referral, and the state office CCSE unit manager will notify the regional director, the state office CCSE Regional Support and Program Implementation unit manager and the state office UR manager within one working day of the decision.

The region must implement the state office decision within 14 days of the region being notified of the decision.