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 12VAC30-60-185 - Utilization review of substance use case management

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions. The following words and terms
				when used in this section shall have the following meanings unless the context
				clearly indicates otherwise:
"Face-to-face" means the same as that term is defined in
				  12VAC30-130-5020.
"Individual service plan" or "ISP" means the same as the term
				  is defined in
				  12VAC30-130-5020.
"Progress notes" means individual-specific documentation that
				  contains the unique differences particular to the individual's circumstances,
				  treatment, and progress that is also signed and contemporaneously dated by the
				  provider's professional staff who have prepared the notes and are part of the
				  minimum documentation requirements that convey the individual's status, staff
				  intervention, and as appropriate, the individual's progress or lack of progress
				  toward goals and objectives in the ISP. The progress notes shall also include,
				  at a minimum, the name of the service rendered, the date of the service
				  rendered, the signature and credentials of the person who rendered the service,
				  the setting in which the service was rendered, and the amount of time or units
				  or hours required to deliver the service. The content of each progress note
				  shall corroborate the time or units billed for each rendered service. Progress
				  notes shall be documented for each service that is billed.
"Register" or "registration" means notifying the Department
				  of Medical Assistance Services or its contractor that an individual will be
				  receiving services that do not require service authorization, such as
				  outpatient services for substance use disorders or substance use case
				  management.
B. Utilization
				review: substance use case management services.
1. The Medicaid enrolled individual shall
				meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria
				for a substance use disorder. Tobacco-related disorders or caffeine-related
				disorders and non-substance-related disorders shall not be covered.
2. Reimbursement shall be provided only for
				"active" case management. An active client for substance use case management
				shall mean an individual for whom there is a current substance use individual
				service plan (ISP) in effect that requires a minimum of two distinct substance
				use case management activities being performed each calendar month and at a
				minimum one face-to-face client contact at least every 90-calendar-day
				period.
3. Billing can be submitted
				for an active recipient only for months in which a minimum of two distinct
				substance use case management activities are performed.
4. An ISP shall be completed within 30
				calendar days of initiation of this service with the individual in a
				person-centered manner and shall document the need for active substance use
				case management before such case management services can be billed. The ISP
				shall require a minimum of two distinct substance use case management
				activities being performed each calendar month and a minimum of one
				face-to-face client contact at least every 90 calendar days. The substance use
				case manager shall review the ISP with the individual at least every 90
				calendar days for the purpose of evaluating and updating the individual's
				progress toward meeting the individualized service plan objectives.
5. The ISP shall be reviewed with the
				individual present, and the outcome of the review shall be documented in the
				individual's medical record.