12VAC30-60-140. Community mental health services.
A. Utilization review general requirements.
utilization Utilization reviews shall be conducted, at a minimum
annually at for each enrolled provider, by the state
Department of Mental Health, Mental Retardation and Substance Abuse Services
(DMHMRSAS) Medical Assistance Services (DMAS) or its contractor.
During each on-site 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.
DMHMRSAS 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
4. Delivered services as documented are consistent with recipients' Individual Service Plans, invoices submitted, and specified service limitations.