Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-5 - Applicability of utilization review requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A. These
				utilization requirements shall apply to all Medicaid covered services unless
				otherwise specified.
B. Some
				Medicaid covered services require an approved service authorization prior to
				service delivery in order for reimbursement to occur. To obtain service
				authorization, all providers' information supplied to the Department of Medical
				Assistance Services (DMAS) or its contractor shall be fully substantiated
				throughout individuals' medical records.
C. Providers shall be required to maintain
				documentation detailing all relevant information about the Medicaid individuals
				who are in the provider's care. Such documentation shall fully disclose the
				extent of services provided in order to support the provider's claims for
				reimbursement for services rendered. This documentation shall be written,
				signed, and dated at the time the services are rendered unless specified
				otherwise.
D. Providers shall
				maintain documentation that demonstrates that individuals providing services
				have the required qualifications established by DMAS, the Department of Health
				Professions (DHP), or the Department of Behavioral Health and Developmental
				Services (DBHDS).
E. DMAS, or its
				contractor, shall perform reviews of the utilization of all Medicaid covered
				services pursuant to
				42 CFR
				440.260 and 42 CFR Part 456.
F. DMAS shall recover expenditures made for
				covered services when providers' documentation does not comport with standards
				specified in all applicable regulations.
G. Providers who are determined not to be in
				compliance with DMAS requirements shall be subject to 12VAC30-80-130 for the
				repayment of those overpayments to DMAS.
H. Utilization review requirements specific
				to community mental health services and residential treatment services,
				including therapeutic group homes and psychiatric residential treatment
				facilities (PRTFs), as set out in 12VAC30-50-130 and 12VAC30-50-226, shall be
				as follows:
1. To apply to be reimbursed as a
				Medicaid provider, the required DBHDS license shall be either a full, annual,
				triennial, or conditional license.
2. Health care entities with provisional
				licenses issued by DBHDS shall not be reimbursed as Medicaid providers
				.
3. Reimbursement shall not be
				permitted to health care entities that fail to enter into a provider contract
				with DMAS or its contractor for a service prior to rendering that service or
				fail to maintain a current Medicaid Provider Enrollment Agreement. If services
				are provided through a managed care organization (MCO), services shall not be
				reimbursed unless the provider is also enrolled with the MCO as a Medicaid
				provider.
4. DMAS or its contractor
				shall apply a national standardized set of medical necessity criteria in use in
				the industry or an equivalent standard authorized in advance by DMAS. Services
				that fail to meet medical necessity criteria shall be denied service
				authorization.
5. Service providers
				shall maintain documentation to establish that services are rendered by
				individuals with appropriate qualifications and credentials, including proof of
				licensure or registration through DHP if applicable. Qualified mental health
				professional-eligibles, as defined by DBHDS, shall maintain documentation of
				supervision and of progress toward the requirements for DHP registration as a
				qualified mental health professional-child or progress toward the requirements
				for DHP registration as a qualified mental health professional-adult as those
				terms are defined by DBHDS.