12VAC30-60-5. Applicability of utilization review requirements.
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.
To obtain service authorization, all providers' information supplied to the
Department of Medical Assistance Services (DMAS) or its contractor shall be
fully substantiated throughout individuals' medical records. 2. C. 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 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
D. Providers shall maintain documentation that demonstrates that individuals providing services have the required qualifications established by DMAS, the Department of Health Professions (DHP), or the Department of Behavioral Health and Developmental Services (DBHDS).
C. E. 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. F. DMAS shall recover expenditures made for
covered services when providers' documentation does not comport with standards
specified in all applicable regulations. E. G. 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. H. 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
1. To apply to be reimbursed as a Medicaid provider, the
Department of Behavioral Health and Developmental Services (DBHDS)
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
2. Health care entities with provisional licenses issued by
DBHDS shall not be reimbursed as Medicaid providers
of community mental
Payments Reimbursement 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, or fail to maintain a current Medicaid Provider
Enrollment Agreement. If services are provided through a Managed Care
Organization (MCO), services shall not be reimbursed unless the provider is
also enrolled with the MCO as a Medicaid provider.
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. Service providers shall maintain documentation to establish that services are rendered by individuals with appropriate qualifications and credentials, including proof of licensure or registration through DHP if applicable. Qualified mental health professional-eligibles (as defined by DBHDS) shall maintain documentation of supervision and of progress toward the requirements for DHP registration as a qualified mental health professional-child or progress toward the requirements for DHP registration as a qualified mental health professional-adult as those terms are defined by DBHDS.