Subchapter G, Utilization Review

Revision 09-1

§47.91 Utilization Review

(a) DADS conducts utilization review of a service delivery plan and supporting documentation at any time to:

(1) determine the appropriateness of services;

(2) validate a service provision; or

(3) evaluate the quality of services.

(b) A provider, consumer directed services employer, and consumer directed services agency must submit documentation supporting the service delivery plan to DADS as requested by DADS.

(c) If DADS determines that one or more of the tasks specified in a service delivery plan do not meet the requirements described in Subchapter D of this chapter (relating to Service Delivery Plan Requirements) and Subchapter E of this chapter (relating to Service Requirements), DADS denies or reduces the hours or tasks, modifies the service delivery plan effective from the date of the utilization review, and sends written notification of the denial or reduction to the individual and provider.

(d) In addition to the utilization review conducted in accordance with subsection (a) of this section, DADS may conduct utilization reviews of providers and services based on utilization patterns and trends.