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 12VAC30-60-181 - Utilization review of addiction and recovery treatment services

Current through Register Vol. 40, No. 24, July 15, 2024
A. 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
				provider's claims for reimbursement for services rendered. This documentation
				shall be written and dated at the time the services are rendered. Claims that
				are not adequately supported by appropriate up-to-date documentation may be
				subject to recovery of expenditures.
B. Utilization reviews shall be conducted by
				the Department of Medical Assistance Services or its designated
				contractor.
C. Service
				authorizations shall be required for American Society of Addiction Medicine
				(ASAM) Levels 2.1, 2.5, 3.1, 3.3, 3.5, 3.7, and 4.0.
D. A multidimensional assessment by a
				credentialed addiction treatment professional (CATP), as defined in
				12VAC30-130-5020,
				shall be required for ASAM Levels 1.0 through 4.0. Certified substance abuse
				counselors (CSACs) and CSAC-supervisees are able to complete a multidimensional
				assessment under supervision to make recommendations for an ASAM level of care,
				which shall be signed and dated by a CATP within three business days. The
				multidimensional assessment shall be maintained in the individual's record by
				the provider. Medical necessity for all ASAM levels of care shall be based on
				the outcome of the individual's multidimensional assessment.
E. Individual service plans (ISPs) and
				treatment plans shall be developed upon admission to medically managed
				intensive inpatient services (ASAM Level 4.0), substance use residential and
				inpatient services (ASAM Levels 3.1, 3.3, 3.5, and 3.7), and substance use
				intensive outpatient and partial hospitalization programs (ASAM Levels 2.1 and
				2.5). ISPs or treatment plans shall be developed upon initiation of opioid
				treatment services (OTP), office-based addiction treatment (OBAT), and
				substance use outpatient services (ASAM Level 1.0).
1. The provider shall include the individual
				and the family or caregiver, as may be appropriate, in the development of the
				ISP or treatment plan. To the extent that the individual's condition requires
				assistance for participation, assistance shall be provided. The ISP shall be
				updated at least annually and as the individual's needs and progress change. An
				ISP that is not updated either annually or as the individual's needs and
				progress change shall be considered outdated.
2. All ISPs shall be completed and
				contemporaneously signed and dated by the CATP preparing the ISP. The ISP may
				be completed by a CSAC or CSAC-supervisee under supervision if the CATP signs
				and dates the ISP within three business days.
3. The child's or adolescent's ISP shall also
				be signed by the parent or legal guardian, and the adult individual shall sign
				his own ISP. If the individual, whether a child, adolescent, or adult, is
				unwilling or unable to sign the ISP, then the service provider shall document
				the reasons why the individual was not able or willing to sign the
				ISP.