Virginia Administrative Code
Title 12 - HEALTH
Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Chapter 122 - COMMUNITY WAIVER SRVICES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES
Section 12VAC30-122-230 - Utilization review and quality management review
Universal Citation: 2 VA Admin Code 30-122-230
Current through Register Vol. 41, No. 3, September 23, 2024
A. Quality management review shall be performed by DMAS or its designee. Utilization review of rendered services shall be conducted by DMAS or its designee.
B. DMAS staff shall conduct utilization review of individual-specific provider documentation, which shall be forwarded by providers upon DMAS or DBHDS request.
C. Utilization review requirements specific to services in the developmental disability waivers shall be as follows:
1. To apply to be reimbursed as a Medicaid
provider, the required DBHDS license shall be either a conditional or full
(either annual or triennial) license.
2. Providers with provisional licenses issued
by DBHDS shall not be reimbursed as Medicaid providers beginning 60 days from
the issuance of the provisional license. Providers shall not request or receive
authorizations or reauthorizations for services for new or currently supported
individuals upon the issuance of the provisional license.
3. Reimbursement shall not be permitted to
providers that fail to enter into a provider agreement with DMAS for a service
prior to rendering that service or fail to maintain a current Medicaid Provider
Enrollment Agreement.
Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Disclaimer: These regulations may not be the most recent version. Virginia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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