Virginia Administrative Code
Title 12 - HEALTH
Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE
Section 12VAC30-60-140 - Community mental health services
Universal Citation: 2 VA Admin Code 30-60-140
Current through Register Vol. 41, No. 3, September 23, 2024
A. 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. 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.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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