42 CFR § 456.23
Post-payment review process
June 11, 2020
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.