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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 5. Applicability of utilization review requirements.
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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.
1. To obtain service authorization, all providers' information supplied to the Department of Medical Assistance Services (DMAS), service authorization contractor, or the behavioral health service authorization contractor shall be fully substantiated throughout individuals' medical records.
2. Providers shall be required to maintain documentation detailing all relevant information about the Medicaid individuals who are in providers' care. Such documentation shall fully disclose the extent of services provided in order to support providers' claims for reimbursement for services rendered. This documentation shall be written, signed, and dated at the time the services are rendered unless specified otherwise.
C. DMAS, or its designee, shall perform reviews of the utilization of all Medicaid covered services pursuant to 42 CFR 440.260 and 42 CFR Part 456.
D. DMAS shall recover expenditures made for covered services when providers' documentation does not comport with standards specified in all applicable regulations.
E. 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.
F. Utilization review requirements specific to community mental health services, 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 Department of Behavioral Health and Developmental Services (DBHDS) license shall be either a full, annual, triennial, or conditional license. Providers must be enrolled with DMAS or the BHSA to be reimbursed. Once a health care entity has been enrolled as a provider, it shall maintain, and update periodically as DMAS requires, a current Provider Enrollment Agreement for each Medicaid service that the provider offers.
2. Health care entities with provisional licenses shall not be reimbursed as Medicaid providers of community mental health services.
3. Payments shall not be permitted to health care entities that either hold provisional licenses or fail to enter into a Medicaid Provider Enrollment Agreement for a service prior to rendering that service.
4. The behavioral health service authorization contractor shall apply a national standardized set of medical necessity criteria in use in the industry, such as McKesson InterQual Criteria, or an equivalent standard authorized in advance by DMAS. Services that fail to meet medical necessity criteria shall be denied service authorization.
Historical Notes
Derived from Volume 31, Issue 09, eff. January 30, 2015.