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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4 Texas Health Steps (THSteps) Dental : 4.4 Utilization Review

4.4
HHSC or a designated entity may conduct utilization reviews through automated analysis of a provider’s pattern(s) of practice, including peer group analysis. Such analysis may result in a subsequent on-site utilization review. HHSC or its claims processing contractor may conduct utilization reviews at the direction of the Office of Inspector General (OIG), according to HHSC rules.
DSHS may also conduct dental utilization reviews of randomly selected THSteps dental providers. These reviews compare Medicaid dental services that have been reimbursed to a dental provider to the results of an oral examination of the client as conducted by DSHS regional dentists.
Refer to:
25 TAC, §33.72 for more information about utilization review.

Texas Medicaid & Healthcare Partnership
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