1. Field Utilization Review Waiver/Community Services UR
Utilization Management and Review (UMR)
Access and Intake
DADS

2. Mandates
General Appropriations Act, Article ll, Rider 36, SB 1.
General Appropriations Act, Article II, Sec. 56b.
Mandates the use of utilization management and utilization review practices as necessary to ensure that the:
appropriate scope and level of services are provided to individuals receiving services in Medicaid 1915(c) waivers administered by the department, and
ensure compliance with the cost-effectiveness requirement of Centers for Medicare and Medicaid Services (CMS).

3. Process face-to-face visit with the individual
based on statewide, statistically valid, random sample of individuals currently enrolled in the identified program

4. Field UR Implemented Started FY ‘09
Community Based Alternatives (CBA) (Will be transferred to HHSC FY ‘15)
Medically Dependent Children Program (MDCP) (Will be transferred to HHSC FY ‘16)
Primary Home Care (PHC) (Will be transferred to HHSC FY ‘15)
Started FY ‘13
Community Living Assistance and Support Services (CLASS)
Home and Community Services (HCS)
Texas Home Living (TxHmL)
Starting FY ‘14
Deaf Blind with Multiple Disabilities (DBMD)

5. FY 2013 Sample Size Program Concurrent Total 1081 1109 CLASS 347 HCS
379
TxHmL
355
Total
1081
CBA
372
MDCP
356
PHC
381
1109

6. Field UR Staff State Office Four Regional Office Managers
San Antonio (covers Regions 6 and 8)
Paris (covers Regions 4 and 5)
Weslaco (covers Regions 7 and 11)
Abilene (covers Regions 1,2,3,9 and 10)
Each office employs Registered Nurses
who perform the utilization reviews.

7. Sample Selection
The sample is based upon a statewide, statistically valid, random selection
The sample is determined from the list of individuals currently enrolled in the identified program
The sample is proportionate to the number of individuals served in each region

8. The UR Assessment Includes:
Record Review: encompasses one year of service provision. The documentation request may go back further than one year if necessary.
Interview and observation: a face-to-face visit with the individual, primary caregiver, nurses, attendants, therapists and others as appropriate.
Contact will be made with the provider, service coordinator, and FMSA as applicable.

9. What Process Should Service Coordinators and Provider Staff Expect?
UR nurse:
Reviews the HCS/TxHmL CARE information
Notifies the service coordinator
Submits a fax request to the service coordinator for the required documents
Conducts a desk review of faxed documentation
Contacts service coordinator, individual and/or LAR to arrange face-to-face visit

10. Continued: Conducts face-to-face visit(s)
Requests additional information or clarification as needed
Presents results of UR to the Regional Unit Manager for evaluation of prospective findings and potential referrals
Notifies the service coordinator of visit outcome

11. Continued:
Faxes DADS Form 2067 to the service coordinator summarizing the findings that will affect the current IPC
Accepts and reviews additional information from the service planning team
Finalizes findings

12. Potential Outcomes:
Based on the assessment the UR nurse may determine:
The IPC is accepted as written, or
A need to take one or more of the following actions:
Add a service not currently authorized
Increase a service
Reduce a service
Deny/End a service

13. Findings Resulting in IPC Change
The UR Regional Manager submits the findings to the Central Office PE/UR staff
The PE/UR staff will revise the authorized services and amounts in CARE if changes have not been made by the provider (HCS) or service coordinator (TxHmL).
PE/UR staff notifies the individual of the right to appeal and faxes a copy of the notice to the Local Authority and provider.

14. Other Potential UR Actions
A Referral to:
911
Adult Protective Services/Child Protective Services
Consumer Rights and Services
Office of Inspector General, Waste, Abuse and Fraud
Individual
Provider
Solicitation
Texas Board of Nursing
Other

15. The initiation of UR was communicated to providers through the following information letters:
CLASS, HCS, TxHmL, DMBD
Information Letter No Implementation of Expanded Utilization Review Activities (January 25,2012)
Information Letter No Expansion of Utilization Management and Review Activities (November 5, 2010)

16. Contacts Regions 1, 2, 3, 9, 10 Regions 4, 5 Regions 6, 8, 7(partial)
Delio Herrera, UR Nurse Manager,
Regions 4, 5
Cynthia Ukhun, UR Nurse Manager,
Regions 6, 8, 7(partial)
Alma Trevino, UR Nurse Manager,
Regions 7, 11
Olga Reyna, UR Nurse Manager,
State Office
Susan Peterson, Unit Manager,

17. Thank you!