42 C.F.R. Subpart B—Utilization Control: All Medicaid Services
Title 42 - Public Health
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) Recipient utilization profiles; (2) Provider service profiles; and (3) Exceptions criteria; and (b) Identifies exceptions so that the agency can correct misutilization practices of recipients and providers.
Title 42: Public Health
PART 456—UTILIZATION CONTROL
Subpart B—Utilization Control: All Medicaid Services
§ 456.21 Scope.
§ 456.22 Sample basis evaluation of services.
§ 456.23 Post-payment review process.
