12VAC30-60-5. Applicability of utilization review requirements.

A. In accordance with the requirements in 42 C.F.R. Part 456 concerning utilization control of Medicaid services, the Department or its contractor shall implement utilization control measures, including but not limited to service authorization requirements, post-payment reviews, quality management reviews, and other reviews to monitor quality and appropriate utilization of Medicaid services.  These utilization requirements shall apply to all Medicaid covered services unless otherwise specified.

B. Service authorization.  Some Medicaid covered services require an approved service authorization prior to service delivery in order to be considered for reimbursement to occur. Service authorization means the process to approve specific services for an enrolled Medicaid, FAMIS Plus, or FAMIS individual by a DMAS service authorization contractor prior to service delivery and reimbursement in order to validate that the service requested is medically necessary and meets DMAS and DMAS contractor criteria for reimbursement. Service authorization does not guarantee payment for the service.

1. To obtain service authorization, all providers' information supplied to providers shall supply the Department of Medical Assistance Services (DMAS) or its contractor shall be with information supporting the medical necessity for the requested service that is fully substantiated throughout documented in individuals' medical records.

2. 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 requests for service authorization and the provider's claims for reimbursement for services rendered. This documentation shall be written, signed, and dated at the time the services are rendered unless specified otherwise.

3. Continued authorization requests shall include the documentation requirements in subdivisions 1 and 2, as well as documentation of the individual's current status and the individual's progress, or lack of progress, towards goals and objectives in the ISP.

C. DMAS, or its contractor, shall perform reviews of the utilization of all Medicaid covered services pursuant to 42 CFR 440.260 and 42 CFR Part 456.

D. C. DMAS or its contractor shall recover expenditures made for covered services when providers' documentation does not comport with standards specified in all applicable laws, regulations, and provider agreement requirements.

E. D. Providers who are determined not to be in compliance with DMAS applicable laws, regulations, or provider agreement 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 and residential treatment services, including therapeutic group homes and psychiatric residential treatment facilities (PRTFs), 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 its contractor to be reimbursed. Once a health care entity has been enrolled as a provider, it shall maintain, and update periodically as DMAS or its contractor 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 provider contract with DMAS or its contractor for a service prior to rendering that service.

4. DMAS or its contractor shall apply a national standardized set of medical necessity criteria in use in the industry or an equivalent standard authorized in advance by DMAS. Services that fail to meet medical necessity criteria shall be denied service authorization.

5. For purposes of Medicaid reimbursement for services provided by staff in residency, the following terms shall be used after their signatures to indicate such status:

a. An LMHP-R shall use the term "Resident" after his signature.

b. An LMHP-RP shall use the term "Resident in Psychology" after his signature.

c. An LMHP-S shall use the term "Supervisee in Social Work" after his signature.

12VAC30-60-140. Community mental health services.

A.  In accordance with the requirements in 42 C.F.R. Part 456 concerning utilization control of Medicaid services, the Department or its contractor shall implement utilization control measures for all community mental health services, including but not limited to service authorization requirements, post-payment reviews, quality management reviews, and other reviews to monitor quality and appropriate utilization of Medicaid services. Utilization control measures for these services shall be performed in accordance with the general requirements of 12VAC30-60-5 and this section, as well as the more specific requirements contained in 12VAC30-60-61 and 12VAC30-60-143.

B.  Service Authorization.

1. Initial service authorization requests shall:  (i) document how the individual's behaviors within the last 30 calendar days demonstrate that each of the medical necessity criteria for the service have been met; (ii) document how the individual's behaviors within the last 30 calendar days support the need for the number of service units and the span of dates requested; and (iii) demonstrate individualized and comprehensive treatment planning. 

2. Continued authorization requests shall include the documentation requirements in subdivision 1, as well as documentation of the individual's current status and the individual's progress, or lack of progress, towards goals and objectives in the ISP.

A. C. Utilization review general requirements. Utilization reviews shall be conducted, at a minimum annually for each enrolled provider, by the Department of Medical Assistance Services (DMAS) or its contractor. During each review, an appropriate sample of the provider's total Medicaid population will be selected for review. An expanded review shall be conducted if an appropriate number of exceptions or problems are identified.

B. D. The review by DMAS or its contractor shall include the following items:

1. Medical or clinical necessity of the delivered service;.

2. The admission to service and level of care was appropriate;.

3. The services were provided by appropriately qualified individuals as defined in the Amount, Duration, and Scope of Services found in 12VAC30-50; and.

4. Delivered services as documented are consistent with recipients' Individual Service Plans, invoices submitted, and specified service limitations.

5. Licensure.  To qualify as a Medicaid provider of community mental health services, the provider must have either a full, annual, triennial, or conditional license from the Department of Behavioral Health and Developmental Services (DBHDS).   Health care entities with provisional licenses shall not be reimbursed as Medicaid providers of community mental health services.

6.  Enrollment.  All providers must be enrolled with DMAS. If services are provided to a member enrolled in a Medicaid managed care organization (MCO), the provider shall also follow the MCO enrollment requirements. Once a provider has been enrolled, it shall maintain, and update periodically as DMAS and the MCO requires, current provider enrollment documentation for each Medicaid service that the provider offers.