26B-3-104. Division responsibilities -- Emphasis -- Periodic assessment.
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Effective 5/3/2023
26B-3-104. Division responsibilities -- Emphasis -- Periodic assessment.
(1)In accordance with the requirements of Title XIX of the Social Security Act and applicable federal regulations, the division is responsible for the effective and impartial administration of this chapter in an efficient, economical manner. The division shall:
(a)establish, on a statewide basis, a program to safeguard against unnecessary or inappropriate use of Medicaid services, excessive payments, and unnecessary or inappropriate hospital admissions or lengths of stay;
(b)deny any provider claim for services that fail to meet criteria established by the division concerning medical necessity or appropriateness; and
(c)place its emphasis on high quality care to recipients in the most economical and cost-effective manner possible, with regard to both publicly and privately provided services.
(2)The division shall implement and utilize cost-containment methods, where possible, which may include:
(a)prepayment and postpayment review systems to determine if utilization is reasonable and necessary;
(b)preadmission certification of nonemergency admissions;
(c)mandatory outpatient, rather than inpatient, surgery in appropriate cases;
(d)second surgical opinions;
(e)procedures for encouraging the use of outpatient services;
(f)consistent with Sections 26B-3-105 and 58-17b-606 , a Medicaid drug program;
(g)coordination of benefits; and
(h)review and exclusion of providers who are not cost effective or who have abused the Medicaid program, in accordance with the procedures and provisions of federal law and regulation.
(3)The state Medicaid director shall periodically assess the cost effectiveness and health implications of the existing Medicaid program, and consider alternative approaches to the provision of covered health and medical services through the Medicaid program, in order to reduce unnecessary or unreasonable utilization.
(a)The department shall ensure Medicaid program integrity by conducting internal audits of the Medicaid program for efficiencies, best practices, and cost avoidance.
(b)The department shall coordinate with the Office of the Inspector General for Medicaid Services created in Section 63A-13-201 to implement Subsection
(2)and to address Medicaid fraud, waste, or abuse as described in Section 63A-13-202 .
Renumbered and Amended by Chapter 306 , 2023 General Session