Collapse to view only § 456.21 - Scope.
- § 456.21 - Scope.
- § 456.22 - Sample basis evaluation of services.
- § 456.23 - Post-payment review process.
§ 456.21 - Scope.
This subpart prescribes utilization control requirements applicable to all services provided under a State plan.
§ 456.22 - Sample basis evaluation of services.
To promote the most effective and appropriate use of available services and facilities the Medicaid agency must have procedures for the on-going evaluation, on a sample basis, of the need for and the quality and timeliness of Medicaid services.
§ 456.23 - Post-payment review process.
The agency must have a post-payment review process that—
(a) Allows State personnel to develop and review—
(1) Beneficiary utilization profiles;
(2) Provider service profiles; and
(3) Exceptions criteria; and
(b) Identifies exceptions so that the agency can correct misutilization practices of beneficiaries and providers.