8100, Description

Revision 18-0; Effective September 4, 2018

Utilization Review (UR) is a division within the Medicaid and Children’s Health Insurance Program (CHIP) Division of the Texas Health and Human Services Commission (HHSC). UR was created by Senate Bill 348, 83rd Legislature Regular Session, 2013. This bill amended Title 4 Texas Government Code Section 533.00281 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 appropriate utilization 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 allow UR access to documents, assessments, notes and authorizations contained in the MCO STAR Kids member’s file available upon request. STAR Kids MCOs must participate and make appropriate staff available for reviews conducted by UR upon request from that division.