reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 122 - COMMUNITY WAIVER SRVICES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES › Form - FORMS (12VAC30-122)

Current through Register Vol. 40, No. 24, July 15, 2024
Supports Intensity Scale - Adult
				  VersionTM (ages 16 and up), SIS-A, copyright 2015,
				  American Association on Intellectual and Developmental Disabilities
Supports Intensity Scale - Children's
				  VersionTM (ages 5-16), SIS-C, copyright 2016,
				  American Association on Intellectual and Developmental Disabilities
Virginia
				  Supplemental Questions (eff. 10/2014)
Virginia
				  Developmental Disabilities Autism Competencies, DMAS P-201 (rev.
				  9/2017)
Medicaid
				  Long-Term Care Communication Form, DMAS-225 (rev. 12/2015)
Virginia
				  Individual Developmental Disabilities Eligibility Survey - Infants' Version,
				  DMAS-P235 (eff. 3/2016)
Virginia
				  Individual Developmental Disabilities Eligibility Survey - Children's Version,
				  DMAS-P236 (eff. 4/2016)
Virginia
				  Individual Developmental Disabilities Eligibility Survey - Adult Version,
				  DMAS-P237 (eff. 3/2016)
Virginia
				  Developmental Disabilities Behavioral Competencies, DMAS P241a (rev.
				  9/2017)
Developmental
				  Disabilities DSP and Supervisor Competencies Checklist, DMAS 241a (eff.
				  7/2021)
Direct
				  Support Professional Assurance to Confirm Successful Completion of Training and
				  Testing Requirements for the DD Waivers, DMAS P242a (eff.
				  5/2021)
Department
				  of Behavioral Health and Developmental Services Health Competencies Checklist,
				  DMAS P244a (rev. 1/2017)
Supervisor
				  Assurance, DMAS P245a (eff. 7/2021)
Community
				  Housing Guide: Housing Road Map (eff. 10/2019)
Community
				  Housing Guide: Tenant Screening (eff. 10/2019)
Family and Individual Supports Request for Supervision Hours in Personal
				  Assistance, DMAS-P257 (eff. 5/2021)
Community Learning Request for Supervision Hours in Personal Assistance,
				  DMAS-P257 (eff. 5/2021)
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part I - Outpatient Physical Rehabilitative Services (Repealed) › Section 12VAC30-130-10

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part I - Outpatient Physical Rehabilitative Services (Repealed) › Section 12VAC30-130-15

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part I - Outpatient Physical Rehabilitative Services (Repealed) › Section 12VAC30-130-20

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part I - Outpatient Physical Rehabilitative Services (Repealed) › Section 12VAC30-130-30

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part I - Outpatient Physical Rehabilitative Services (Repealed) › Section 12VAC30-130-40

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part I - Outpatient Physical Rehabilitative Services (Repealed) › Section 12VAC30-130-42

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part I - Outpatient Physical Rehabilitative Services (Repealed) › Section 12VAC30-130-50

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part I - Outpatient Physical Rehabilitative Services (Repealed) › Section 12VAC30-130-60

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part II - Long-Stay Acute Care Hospitals › Section 12VAC30-130-80 - Scope

Current through Register Vol. 40, No. 24, July 15, 2024
Medicaid shall cover long-stay acute care hospital services
					 as defined in
					 12VAC30-130-90 provided by
					 hospitals certified as long-stay acute care hospitals and which have provider
					 agreements with the Department of Medical Assistance
					 Services.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part II - Long-Stay Acute Care Hospitals › Section 12VAC30-130-90 - Authorization for services

Current through Register Vol. 40, No. 24, July 15, 2024
Long-stay acute care hospital stays shall be preauthorized
					 by the submission of a completed comprehensive assessment instrument, a
					 physician certification of the need for long-stay acute care hospital
					 placement, and any additional information that justifies the need for intensive
					 services. Prior authorization shall be required by submission of the
					 information described above. Physician certification must accompany the
					 request. Periods of care not authorized by the Department of Medical Assistance
					 Services shall not be approved for payment.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part II - Long-Stay Acute Care Hospitals › Section 12VAC30-130-100 - Criteria for long-stay acute care hospital stays

Current through Register Vol. 40, No. 24, July 15, 2024
A. Adult long-stay acute care hospital
				  criteria.
1. The resident must have long-term
				  health conditions requiring close medical supervision, 24-hour licensed nursing
				  care, and specialized services or equipment needs. The population to be served
				  includes individuals requiring mechanical ventilation, individuals with
				  communicable diseases requiring universal or respiratory precautions,
				  individuals requiring ongoing intravenous medication or nutrition
				  administration, and individuals requiring comprehensive rehabilitative therapy
				  services.
2. At a minimum, the
				  individual must require physician visits at least once weekly, licensed nursing
				  services 24 hours a day (a registered nurse whose sole responsibility is the
				  designated unit must be on the nursing unit on which the resident resides, 24
				  hours a day), and coordinated multidisciplinary team approach to meet
				  needs.
3. In addition, the
				  individual must meet at least one of the following requirements:
a. Must require two out of three of the
				  following rehabilitative services: physical therapy, occupational therapy,
				  speech-pathology services; each required therapy must be provided daily, five
				  days per week, for a minimum of one hour each day; individual must demonstrate
				  progress in overall rehabilitative plan of care on a monthly basis;
				  or
b. Must require special
				  equipment such as mechanical ventilators, respiratory therapy equipment (that
				  has to be supervised by a licensed nurse or respiratory therapist), monitoring
				  device (respiratory or cardiac), kinetic therapy; or
c. The individual must require at least one
				  of the following special services:
(1)
				  Ongoing administration of intravenous medications or nutrition (i.e. total
				  parenteral nutrition (TPN), antibiotic therapy, narcotic administration,
				  etc.);
(2) Special infection
				  control precautions such as universal or respiratory precaution (this does not
				  include handwashing precautions only);
(3) Dialysis treatment that is provided
				  on-unit (i.e. peritoneal dialysis);
(4) Daily respiratory therapy treatments that
				  must be provided by a licensed nurse or a respiratory therapist;
(5) Extensive wound care requiring
				  debridement, irrigation, packing, etc., more than two times a day (i.e. grade
				  IV decubiti; large surgical wounds that cannot be closed; second- or
				  third-degree burns covering more than 10% of the body); or
(6) Multiple unstable ostomies (a single
				  ostomy does not constitute a requirement for special care) requiring frequent
				  care (i.e. suctioning every hour, stabilization of feeding, stabilization of
				  elimination, etc.)
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part II - Long-Stay Acute Care Hospitals › Section 12VAC30-130-120 - Long-stay acute care hospital services

Current through Register Vol. 40, No. 24, July 15, 2024
All services must be provided by appropriately qualified
					 personnel. The following services are covered long-stay acute care hospital
					 services:
A. Physician services.
1. Physician services shall be performed by a
				  professional who is licensed to practice in the Commonwealth, who is acting
				  within the scope of his license, and who is a doctor of medicine or osteopathy,
				  a doctor of dental surgery or dental medicine, a doctor of podiatric medicine,
				  a doctor of optometry, or a chiropractor.
2. An attending physician means a physician
				  who is a doctor of medicine or osteopathy and is identified by the individual
				  as having the most significant role in the determination and delivery of the
				  individual's medical care.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part III - Preadmission Screening and Annual Resident Review › Section 12VAC30-130-150 - Persons subject to nursing home preadmission screening and identification of conditions of mental illness and mental retardation (Level I)

Current through Register Vol. 40, No. 24, July 15, 2024
A. As a
				  condition of a nursing facility's Medicaid participation, all persons applying
				  for admission shall be screened to determine whether they have a condition of
				  mental illness (MI) or mental retardation (MR) or a related condition (RC), and
				  if so, whether they require the level of services provided by a nursing
				  facility (NF). Nursing facilities shall ensure that applicants for admission
				  have been screened and those who are identified as being MI or MR/RC are not
				  admitted Until determinations have been made by the State Mental Health or
				  Mental Retardation Authority (MH/MHA) with respect to their placement. NHPASCs
				  complete the Level I process for individuals who are Medicaid eligible or
				  expect to become Medicaid eligible within 180 days. Nursing facilities must
				  ensure that the appropriate screenings are conducted for non-Medicaid eligible
				  applicants.
B. No individual,
				  regardless of pay status, may be admitted to a nursing facility unless the
				  Level I screening has been completed, and, if it is determined that the
				  individual has a condition of MI or MR/RC as defined herein, then he or she
				  shall not be admitted Until the Level II determination has been made.
C. The Level I identification function shall
				  provide at least, in the case of first time identifications, for the issuance
				  of written notice to the individual or resident and his or her legal
				  representative if the individual is suspected of having MI or MR/RC and is
				  being referred to the MH/MRA for Level II screening. The NHPASC shall send this
				  notice to Medicaid-eligible individuals who are referred for a Level II
				  screening. The admitting NF shall send the notice to non-Medicaid
				  individuals.
D. All Level I and
				  Level II determinations shall be recorded in the individual's medical
				  record.
E. When a preadmission
				  screening has not been performed timely, but is performed at a later date,
				  federal financial participation (FFP) is available only for services furnished
				  after the screening has been performed.
F. The state in which the individual is a
				  resident (or will be at the time he or she becomes eligible for Medicaid) must
				  pay for the PASARR and make the required determinations. In the case of
				  non-Medicaid eligible applicants, the receiving NF is responsible to ensure
				  that the appropriate screenings have been completed prior to the individual's
				  admission.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part III - Preadmission Screening and Annual Resident Review › Section 12VAC30-130-160 - Level II determination

Current through Register Vol. 40, No. 24, July 15, 2024
A. For each
				  resident of a NF who has a condition of MI or MR/RC, the MH/MRA, as
				  appropriate, must determine whether the individual requires the level of
				  services provided by a NF, an inpatient psychiatric hospital for individuals
				  under age 21, an institution for mental disease (IMD) providing medical
				  assistance to individuals age 65 and older, an intermediate care facility for
				  the mentally retarded (ICF/MR), or specialized services for either MI or
				  MR/RC.
B. When a Level II
				  evaluation is required, a determination shall be made within an annual average
				  of seven to nine working days of the referral for screening. The MH/MRA shall
				  convey determinations verbally to NFs and the individual and confirm them in
				  writing.
C. The MH/MRA shall notify
				  in writing the following entities of a Level II determination:
1. The evaluated individual and his or her
				  legal representative;
2. The
				  admitting or retaining NF;
3. The
				  individual or resident's attending physician; and
4. The discharging hospital.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part III - Preadmission Screening and Annual Resident Review › Section 12VAC30-130-170 - Categorical determinations

Current through Register Vol. 40, No. 24, July 15, 2024
A. For each
				  individual for whom the Level I screening has resulted in the determination
				  that the individual meets nursing facility level of care and has a condition of
				  MI or MR/RC as defined herein, a Level II evaluation does not have to be
				  completed if one of the following categorical determinations are met:
1. The individual has a terminal illness in
				  which a physician has documented that life expectancy is less than six months;
				  or
2. The individual has a severe
				  illness such as coma, functioning at brain stem level, or other conditions
				  which result in a level of impairment so severe that the individual could not
				  be expected to benefit from specialized services. When this category is used,
				  documentation shall be available which fully describes the severity of the
				  condition.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part III - Preadmission Screening and Annual Resident Review › Section 12VAC30-130-180 - Annual resident review

Current through Register Vol. 40, No. 24, July 15, 2024
A. A review and
				  determination must be conducted for each resident of a NF who has MI or MR/RC
				  not less often than annually. "Annually" is defined as occurring within every
				  fourth quarter after the previous preadmission screening or annual resident
				  review.
B. When an annual resident
				  review has not been performed timely, but is performed at a later date, federal
				  financial participation (FFP) is available only for services furnished after
				  the review has been performed.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part III - Preadmission Screening and Annual Resident Review › Section 12VAC30-130-210 - Specialized services

Current through Register Vol. 40, No. 24, July 15, 2024
A. For mental
				  illness, specialized services means the services specified by the state which,
				  combined with services provided by the NF, results in the continuous and
				  aggressive implementation of an individualized plan of care that:
1. Is developed and supervised by an
				  interdisciplinary team which includes a physician, qualified mental health
				  professionals, and as appropriate, other professionals;
2. Prescribes specific therapies and
				  activities for the treatment of persons experiencing an acute episode of
				  serious mental illness which necessitates supervision by trained mental health
				  personnel;
3. Is directed toward
				  diagnosing and reducing the resident's behavioral symptoms that may necessitate
				  institutionalization, improving his or her level of independent functioning,
				  and achieving a functioning level that permits reduction in the intensity of
				  mental health services to below the level of specialized services at the
				  earliest possible time; and
4.
				  Prescribes inpatient psychiatric services for any individual determined to be a
				  danger to self or others. For nursing facility residents who are determined to
				  be a danger to self or others due to mental illness, the nursing facility must
				  coordinate admission to an inpatient psychiatric hospital.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part III - Preadmission Screening and Annual Resident Review › Section 12VAC30-130-230 - Evaluating the need for NF services and NF level of care (PASARR/NF)

Current through Register Vol. 40, No. 24, July 15, 2024
A. For each
				  applicant for admission to a NF and each NF resident who has MI or MR/RC, the
				  evaluator must assess whether (i) the applicant's or resident's total needs are
				  such that his needs can be met in an appropriate community setting; (ii) the
				  individual's total needs are such that they can be met only on an inpatient
				  basis, which may include the option of placement in a home and community-based
				  services waiver program, but for which the inpatient care would be required;
				  (iii) if inpatient care is appropriate and desired, the NF is an appropriate
				  institutional setting for meeting those needs; or (iv) if the inpatient care is
				  appropriate and desired but the NF is not the appropriate setting for meeting
				  the individual's needs, another setting such as an ICF/MR (including small,
				  community-based facilities), an IMD providing services to individuals ages 65
				  or older, or a psychiatric hospital is an appropriate institutional setting for
				  meeting those needs.
B. In
				  determining appropriate placement, the evaluator must prioritize the physical
				  and mental needs of the individual being evaluated, taking into account the
				  severity of each condition.
C. At a
				  minimum the data relied on to make a determination must include:
(i) evaluation of physical status (for
				  example, diagnoses, date of onset, medical history, and prognosis);
(ii) evaluation of mental status (for
				  example, diagnoses, date of onset, medical history, likelihood that the
				  individual may be a danger to himself/herself or others); and
(iii) functional assessment (activities of
				  daily living).
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part III - Preadmission Screening and Annual Resident Review › Section 12VAC30-130-240 - Evaluating whether an individual with MI requires specialized services (PASARR/MI)

Current through Register Vol. 40, No. 24, July 15, 2024
A. The purpose
				  of this section is to identify the minimum data needs and process requirements
				  for the state MHA, which is responsible for determining whether or not the
				  applicant or resident with MI needs a specialized services program for mental
				  illness.
B. Minimum data collected
				  must include:
1. A comprehensive history and
				  physical examination of the person. If the history and physical examination are
				  not performed by a physician, then a physician must review and concur with the
				  conclusions. The following areas must be included (if not previously
				  addressed): complete medical history; review of all body systems; specific
				  evaluation of the person's neurological system in the areas of motor
				  functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves,
				  and abnormal reflexes; and in case of abnormal findings which are the basis for
				  a NF placement, additional evaluations conducted by appropriate
				  specialists.
2. A comprehensive
				  drug history including current or immediate past use of medications that could
				  mask symptoms or mimic mental illness.
3. A psychological evaluation of the person,
				  including current living arrangements and medical and support
				  systems.
4. A comprehensive
				  psychiatric evaluation including a complete psychiatric history, evaluation of
				  intellectual functioning, memory functioning, and orientation, description of
				  current attitudes and overt behaviors, affect, suicidal or homicidal ideation,
				  paranoia, and degree of reality testing (presence and content of delusions) and
				  hallucinations.
5. A functional
				  assessment of the individual's ability to engage in activities of daily living
				  and the level of support that would be needed to assist the individual to
				  perform these activities while living in the community. The assessment must
				  determine whether this level of support can be provided to the individual in an
				  alternative community setting or whether the level of support needed is such
				  that NF placement is required. The functional assessment must address the
				  following areas: Self-monitoring of health status, self-administering and
				  scheduling of medical treatment, including medication compliance, or both,
				  self-monitoring of nutritional status, handling money, dressing appropriately,
				  and grooming.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part III - Preadmission Screening and Annual Resident Review › Section 12VAC30-130-260 - Appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. Following
				  notification to the NF of the Level II assessment determination by the state
				  MH/MRA, the NF must inform the individual of the decision indicating the
				  reasons for acceptance or denial and the method of appeal. Any individual,
				  regardless of method of payment, who wishes to appeal the decision of the Level
				  II evaluation may do so by sending written notification to the Department of
				  Medical Assistance Services, Division of Client Appeals.
B. Decisions made by the annual resident
				  review teams shall also be appealable to DMAS. The reviewed individual shall
				  send written notification to DMAS, Division of Client Appeals.
C. All appeal requests must be made within 30
				  days of the individual's notification of the review decision.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IV - Drug Utilization Review Program › Section 12VAC30-130-280 - Authority

Current through Register Vol. 40, No. 24, July 15, 2024
Section 1927 of Title XIX Social Security Act provides the
					 authority for this program.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IV - Drug Utilization Review Program › Section 12VAC30-130-290 - Scope and purpose

Current through Register Vol. 40, No. 24, July 15, 2024
A. DMAS
				  shall implement and conduct a drug utilization review program (DUR program) for
				  covered drugs prescribed for eligible recipients. The program shall help to
				  ensure that prescriptions are appropriate, medically necessary, and are not
				  likely to cause medically adverse events. The program shall provide for ongoing
				  retrospective DUR, prospective DUR and an educational outreach program to
				  educate practitioners on common drug therapy problems with the aim of improving
				  prescribing practices. As needed, the program shall also provide for electronic
				  messages as well as rejected or denied services when such claims are not
				  consistent with DUR criteria and requirements. The primary objectives shall be:
1. Improving in the quality of
				  care;
2. Maintaining program
				  integrity (i.e., controlling problems of fraud and benefit abuse);
				  and
3. Conserving program funds and
				  individual expenditures.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IV - Drug Utilization Review Program › Section 12VAC30-130-300 - Retrospective DUR

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  retrospective DUR program shall provide, through drug claims processing and
				  information retrieval systems, for ongoing periodic examination of claims data
				  and other records in order to identify patterns of fraud, abuse, overuse, or
				  inappropriate or medically unnecessary care among physicians, pharmacists, and
				  individuals receiving benefits under Title XIX of the Social Security
				  Act.
B. The DUR program shall, on
				  an ongoing basis, assess data on drug use against predetermined criteria and
				  standards which have been approved by the DUR Board.
C. Summary data concerning identified
				  exceptional drug utilization patterns shall be developed and submitted by DMAS
				  to the DUR Board at least quarterly, or as often as monthly if requested by the
				  DUR Board. This data shall include at least a summary of the drug therapy
				  problems most often observed in the course of retrospective reviews, summaries
				  of physician responses to educational interventions, and the results of
				  intensified reviews and monitoring of selected prescribers or
				  dispensers.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IV - Drug Utilization Review Program › Section 12VAC30-130-310 - Prospective DUR

Current through Register Vol. 40, No. 24, July 15, 2024
A. Patient
				  medication profile. On and after January 1, 1993, pharmacists shall make a
				  reasonable effort to maintain a patient medication record system for persons
				  covered under Title XIX of the Social Security Act for whom prescriptions are
				  dispensed. For purposes of this regulation, a reasonable effort shall have been
				  made if the information set forth in subdivision 1 of this subsection is
				  requested by the pharmacist or the pharmacist's designee from the patient or
				  the patient's agent.
1. A reasonable effort
				  shall be made by the participating pharmacist to obtain, record, and maintain
				  at least the following information on each patient's profile:
a. Patient's name, address, telephone
				  number;
b. Date of birth (or
				  current age) and gender;
c. Medical
				  history
(1) Significant patient health
				  problems known to the pharmacist,
(2) Prescription drug reactions or known
				  allergies,
(3) A comprehensive list
				  of prescription and nonprescription medications and legend drug administration
				  devices known by the pharmacist to have been used by the patient; and
d. Prescriber information to
				  include, but not necessarily be limited to, name, address, and Medicaid and
				  Drug Enforcement Agency (DEA) provider numbers.
e. Pharmacist's comments relevant to the
				  patient's drug use, including any failure to accept the pharmacist's offer to
				  counsel.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IV - Drug Utilization Review Program › Section 12VAC30-130-320 - Criteria and standards for DUR

Current through Register Vol. 40, No. 24, July 15, 2024
The DUR Board shall establish and revise as necessary a
					 list of approved criteria and standards which shall be consistent with the
					 following:
1. Compendia which shall
				  consist of at least the publications, as may be amended from time to time, that
				  are referenced at
				  12VAC30-10-650 C.
2. The peer-reviewed medical literature;
				  and
3. Commonly accepted standards
				  of medical practice as used by practitioners across the Commonwealth
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IV - Drug Utilization Review Program › Section 12VAC30-130-330 - Educational program

Current through Register Vol. 40, No. 24, July 15, 2024
A. DMAS
				  shall develop an educational program designed to further educate physicians and
				  pharmacists to ensure that prescriptions are appropriate, medically necessary,
				  and are not likely to cause adverse actions. The purpose of such program shall
				  be to:
1. Identify and reduce the frequency
				  of patterns of fraud, abuse, overuse, or inappropriate or medically unnecessary
				  care among physicians, pharmacists, and patients, or associated with specific
				  drugs or groups of drugs;
2.
				  Identify and reduce the potential and actual severe adverse reactions to drugs;
				  and
3. Improve prescribing and
				  dispensing practices.
Such program shall include education on therapeutic
					 appropriateness, overutilization and underutilization, appropriate use of
					 generic products, therapeutic duplication, drug-disease contraindications,
					 drug-drug interactions, incorrect drug dosage or duration of drug treatment,
					 drug-allergy interactions and clinical abuse/misuse.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IV - Drug Utilization Review Program › Section 12VAC30-130-335 - Other interventions

Current through Register Vol. 40, No. 24, July 15, 2024
As permitted by all applicable federal and state laws and
					 regulations, DMAS or its designee may intervene in the process of the
					 adjudication of claims for payment of prescription drugs. Such interventions
					 may entail, but shall not be limited to, electronic messages, rejecting claims
					 pending further resolution, or requiring prior authorization for selected
					 prospective DUR criteria.
Designated interventions may include provider override,
					 obtaining prior authorization via communication to a call center staffed with
					 appropriate clinicians, or written communication to
					 prescribers.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IV - Drug Utilization Review Program › Section 12VAC30-130-340 - DUR Board

Current through Register Vol. 40, No. 24, July 15, 2024
A. The Director
				  of DMAS shall establish the DUR Board either directly or through a contract
				  with an outside vendor. The DUR Board shall submit recommendations on
				  prospective and retrospective drug use review to the director. The director
				  reserves the right to reject such recommendations and shall so notify the board
				  consistent with federal requirements. The DUR Board shall adhere to all the
				  requirements of client confidentiality with respect to patient specific
				  information.
B. The DUR Board shall
				  consist of 13 members. At least one-third of the members shall be pharmacists.
				  At least one-third but no more than 51% of the members shall be physicians.
				  There shall be at least one but no more than two nurse members. All pharmacist,
				  physician and nurse members shall be licensed by the Commonwealth with such
				  licenses in good standing. The Director of DMAS shall invite submission of
				  candidates from each of these groups. Other individuals and groups interested
				  in submitting names of candidates for the DUR Board shall indicate their
				  interest to the director in writing. The director shall appoint the physician
				  members from candidates submitted by the Medical Society of Virginia, the Old
				  Dominion Medical Society, and each of the medical schools in the Commonwealth.
				  The director shall appoint the pharmacist members from candidates submitted by
				  the Medical College of Virginia/Virginia Commonwealth University School of
				  Pharmacy, the Virginia Pharmaceutical Association, Virginia Chain Drug Store
				  Association, and the Virginia Society of Consultant Pharmacists. The director
				  shall appoint the nurse member or members from candidates submitted by the
				  Virginia Nurses Association.
1. At least five
				  of the physicians and pharmacists appointed to the DUR Board shall be licensed
				  and actively practicing.
2. All
				  individuals appointed to the DUR Board shall demonstrate knowledge and
				  expertise in one or more of the following areas:
a. The clinically appropriate prescribing of
				  covered outpatient drugs;
b. The
				  clinically appropriate dispensing and monitoring of outpatient drugs;
c. Drug use review, evaluation, and
				  intervention; and
d. Medical
				  quality assurance.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IV - Drug Utilization Review Program › Section 12VAC30-130-350 - DUR Committee

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  director shall provide for the establishment of a DUR Committee either directly
				  or through a contract with an outside vendor. The DUR Board may serve as the
				  DUR Committee.
B. The membership of
				  the DUR Committee shall include health care professionals who have recognized
				  knowledge and expertise in one or more of the following:
1. The clinically appropriate prescribing of
				  covered drugs;
2. The clinically
				  appropriate dispensing and monitoring of covered drugs;
3. Drug use review, evaluation, and
				  intervention; and
4. Medical
				  quality assurance.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IV - Drug Utilization Review Program › Section 12VAC30-130-360 - Exemption of organized health care settings

Current through Register Vol. 40, No. 24, July 15, 2024
A. Covered outpatient drugs dispensed by
				  health maintenance organizations, including those organizations that contract
				  under § 1903(m) of the Act, are not subject to the requirements of this
				  section.
B. A hospital (providing
				  medical assistance under the Commonwealth's plan) that dispenses covered
				  outpatient drugs using drug formulary systems, and bills DMAS no more than the
				  hospital's purchasing costs for covered outpatient drugs (as determined under
				  the State plan) shall not be subject to the requirements of this
				  regulation.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part V - Drug Utilization Review in Nursing Facilities › Section 12VAC30-130-380 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms, when used in this part,
					 shall have the following meanings unless the context clearly indicates
					 otherwise:
"DMAS" means the Department of Medical Assistance Services
					 consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code
					 of Virginia.
"Drug utilization review" or "DUR" means a formal
					 continuing program for assessing medical or drug use data against explicit
					 standards and, as necessary, introducing remedial strategies.
"Drug Utilization Review Committee (DUR Committee)" means a
					 committee composed of knowledgeable health care professionals who make
					 recommendations for developing and modifying drug therapy review standards or
					 criteria, participate in retrospective reviews, recommend remedial strategies,
					 and evaluate the success of the interventions.
"Exceptional drug utilization pattern" means
(i) a pattern of drug utilization within a
				  nursing facility that differs substantially from predetermined standards
				  established pursuant to
				  12VAC30-130-400 B;
(ii) individual resident's drug use patterns
				  that differ from the established standards; or
(iii) individual resident's drug use patterns
				  that exhibit a high risk for drug therapy induced illness.
"Retrospective utilization drug review" means the drug
					 utilization review process that is conducted using historic or archived medical
					 or drug use data.
"Targeted facility" means a nursing facility where
					 residents' patterns of drug utilization demonstrate an exceptional drug
					 utilization pattern as defined herein.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part V - Drug Utilization Review in Nursing Facilities › Section 12VAC30-130-390 - Scope

Current through Register Vol. 40, No. 24, July 15, 2024
A. Medicaid shall
				  conduct a drug utilization review program for covered drugs prescribed for
				  nursing facility residents. The program shall help to ensure that prescriptions
				  are appropriate, medically necessary, and are not likely to cause adverse
				  actions. The primary objectives are (i) improvement in the quality of care:
				  (ii) conserving program funds and individual expenditures: and (iii)
				  maintaining program integrity (i.e., controlling problems of fraud and benefit
				  abuse).
B. Retrospective drug
				  utilization review will be conducted on an ongoing basis in targeted nursing
				  facilities demonstrating exceptional drug utilization patterns.
C. With the aim of improving prescribing
				  practices, the program shall provide for ongoing educational outreach programs
				  to educate practitioners on common drug therapy problems.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part V - Drug Utilization Review in Nursing Facilities › Section 12VAC30-130-400 - Utilization review process

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  program shall provide, through its drug claims processing and information
				  retrieval systems, for the ongoing periodic retrospective examination of claims
				  data and other records for targeted facilities to identify patterns of
				  inappropriate or medically unnecessary care for individuals receiving benefits
				  under Title XIX of the Social Security Act.
B. The program shall, on an ongoing basis,
				  assess data on drug use against predetermined standards (as described in this
				  section) including, but not limited to, monitoring for therapeutic
				  appropriateness, overutilization and underutilization, appropriate use of
				  generic products, therapeutic duplication, drug-disease contraindications,
				  drug/drug interactions, incorrect drug dosage or duration of treatment,
				  clinical abuse/misuse, fraud, and, as necessary, introduce to physicians and
				  pharmacists remedial strategies in order to improve the quality of
				  care.
C. The Department of Medical
				  Assistance Services may assess data on drug use against such standards as
				  contained in the publications, as may be amended from time to time, that are
				  referenced at
				  12VAC30-10-650 C and any other
				  appropriate peer-reviewed medical literature.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part V - Drug Utilization Review in Nursing Facilities › Section 12VAC30-130-420 - Medical quality assurance

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Documentation of drug regimens in nursing facilities shall, at a minimum:
1. Be included in a plan of care that must be
				  established and periodically reviewed by a physician;
2. Indicate all drugs administered to the
				  resident in accordance with the plan with specific attention to frequency,
				  quantity, and type and identify who administered the drug (include full name
				  and title); and
3. Include the drug
				  regimen review prescribed for nursing facilities in regulations implementing
				  Section 483.60 of Title 42, Code of Federal Regulations.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part VI - Criteria for Intermediate Care for Mentally Retarded Persons › Section 12VAC30-130-430 - Introduction

Current through Register Vol. 40, No. 24, July 15, 2024
A. Utilization
				  control regulations require that the level of care criteria be formulated for
				  guidance for appropriate levels of care. Traditionally, intermediate care for
				  the mentally retarded has been institutionally based; however, this level of
				  care need not be confined to a specific setting. The habilitative and health
				  needs of the client are the determining issues.
B. The purpose of this chapter is to
				  establish standard criteria to measure eligibility for Medicaid payment.
				  Medicaid can pay for care only when the client is in the appropriate level of
				  care and when "active treatment" is being provided. An individual's need for
				  care must meet these criteria before any authorization for payment by Medicaid
				  will be made for either institutional or waivered rehabilitative services for
				  the mentally retarded.
C.
				  Intermediate care for the mentally retarded requires planned programs for
				  habilitative needs or health related services which exceed the level or room,
				  board, combination of habilitative, rehabilitative, and health services
				  directed toward increasing the functional capacity of the retarded person.
				  Examples of services will include training in the activities of daily living,
				  task-learning skills, socially acceptable behaviors, basic community living
				  programming, or health care and health maintenance. The overall objective of
				  programming shall be the attainment of the optimal physical, intellectual,
				  social, or task learning level which the person can presently or potentially
				  achieve.
D. The evaluation and
				  reevaluation for intermediate care are based on the needs of the person, the
				  reasonable expectations of the resident's capabilities, the appropriateness of
				  programming, whether progress is demonstrated from the training and, in an
				  institution, whether the services could reasonably be provided in a less
				  restrictive environment.
E. The
				  final determination of a person's need for intermediate level of care is a
				  professional decision based on total needs. Mentally retarded persons as
				  individuals present an infinite variety of needs, making it virtually
				  impossible to establish an evaluation system that will eliminate the need for
				  professional judgement within the confines of program criteria.
F. The following criteria are divided into
				  broad categories of needs, or services provided. These must be evaluated in
				  detail to determine the abilities/skills which the client has acquired. The
				  evaluation will then identify training needs/skills which will be the basis for
				  the development of a plan of care.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part VI - Criteria for Intermediate Care for Mentally Retarded Persons › Section 12VAC30-130-440 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms, when used in this chapter,
					 shall have the following meanings, unless the context clearly indicates
					 otherwise:
"No assistance" means no help is needed.
"Often" means occurs two to three times a month.
"Prompting/structuring" means prior to the functioning,
					 some verbal direction or rearrangement of the environment is needed.
"Rarely" means occurs quarterly or less.
"Regularly" means occurs weekly or more.
"Some direct assistance" means helper must be present and
					 provide some physical guidance/support (with or without verbal
					 direction).
"Sometimes" means occurs once a month.
"Supervision" means helper must be present during function
					 and provide only verbal direction, gestural prompts, or guidance.
"Total assistance" means helper must perform all or nearly
					 all of the functions.
Statutory Authority
§ 32.1-325 of the Code of Virginia.