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Virginia Administrative Code (Last Updated: January 10, 2017) |
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Title 12. Health |
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Agency 30. Department of Medical Assistance Services |
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Chapter 60. Standards Established and Methods Used to Assure High Quality Care |
Section 185. Utilization review of case management
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A. Utilization review: community substance abuse treatment services.
1. The Medicaid recipient shall meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria for an Axis I substance-related disorder. Nicotine or caffeine abuse or dependence shall not be covered.
2. Reimbursement shall be provided only for "active" case management. An active client for case management shall mean an individual for whom there is a plan of care in effect that requires regular direct or client-related contacts or activity or communication with the client or families, significant others, service providers, and others including a minimum of one face-to-face client contact within a 90-day period.
3. Except for a 30-day period following the initiation of this case management service by the recipient, in order to continue receiving case management services, the Medicaid recipient must be receiving another substance abuse treatment service.
4. Billing can be submitted for an active recipient only for months in which direct or client-related contacts, activity, or communications occur.
5. There is a maximum annual service limit of 52 hours for case management services.
6. An initial Individual Service Plan (ISP) must be completed and must document the need for active case management before case management services can be billed. A comprehensive ISP shall be fully developed within 30 days of initiation of this service, which requires regular direct or recipient-related contacts or activity or communication with the recipient or families, significant others, service providers, and others including a minimum of one face-to-face client contact every 90 days. The case manager shall review the ISP every 90 days for the purpose of updating it or otherwise modifying it as appropriate for the recipient's changing condition.
7. The ISP shall be updated at least every 90 days or within seven days of a change in the recipient's treatment.
B. Utilization review: substance abuse treatment case management services.
1. Utilization review general requirements. On-site utilization reviews shall be conducted. Reimbursement shall be provided only for "active" case management clients. An active client for case management shall mean an individual for whom there is a plan of care in effect that requires regular direct or client-related contacts or activity or communication with the client or families, significant others, service providers, and others including a minimum of one face-to-face client contact within a 90-day period. Billing can be submitted only for months in which direct or client-related contacts, activity or communications occur.
2. The Medicaid eligible individual shall meet the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR) criteria for an Axis I Substance Abuse Disorder, with the exception of nicotine or caffeine abuse or dependence. A diagnosis of nicotine or caffeine abuse or dependence alone shall not be sufficient for reimbursement of these services.
3. The maximum annual limit for substance abuse treatment case management shall be 52 hours per year. Case management shall not be billed for persons in institutions for mental disease. Substance abuse treatment case management shall not be billed concurrently with any other type of Medicaid reimbursed case management.
4. The ISP must document the need for case management and be fully completed within 30 days of initiation of the service and the case manager shall review the ISP every three months. Such reviews must be documented in the client's record. The review will be due by the last day of the third month following the month in which the last review was completed. If needed a grace period will be granted up to the last day of the fourth month following the month of the last review. When the review was completed in a grace period, the next subsequent review shall be scheduled three months from the month the review was due and not the date of actual review.
5. The ISP shall be updated at least annually.
6. The provider of case management services shall be licensed by DBHDS as a provider of case management services.
Historical Notes
Derived from Volume 26, Issue 08, eff. January 21, 2010.