Virginia Administrative Code
Title 12 - HEALTH
Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN
Part VI - Quality Assurance and Utilization Control
Section 12VAC30-141-650 - Provider review

A. The provider review unit shall be responsible for reviewing enrolled FAMIS providers to identify potential inappropriate utilization of services and potential billing errors.

B. Providers agree to keep such records as DMAS determines necessary. The providers shall furnish DMAS, upon request, information regarding payments claimed for providing services under the State Plan for Title XXI.

C. Access to records and facilities by authorized DMAS representatives shall be permitted upon request.

D. Providers shall be required to refund payments made by DMAS if they are found to have billed DMAS contrary to policy, failed to maintain records or adequate documentation to support their claims, or billed for medically unnecessary services.

E. A review of adverse actions concerning provider reimbursement shall be heard in accordance with the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia) and the Virginia Administrative Code, 12VAC30-10-1000 and 12VAC30-20-500 through 12VAC30-20-560.

F. MCHIPs shall be responsible for keeping provider profile and utilization mechanisms to monitor provider activities. MCHIPs shall be reviewed by DMAS.