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| Subpart B | Utilization Control: All Medicaid Services | 456.21 – 456.23 | |||||||||
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43 FR 45266, Sept. 29, 1978, unless otherwise noted.
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This subpart prescribes utilization control requirements applicable to all services provided under a State plan.
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.
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.