Current through Register Vol. 41, No. 3, September 23, 2024
A. Definitions.
The following words and terms when used in this section shall have the
following meanings unless the context clearly indicates otherwise:
"Face-to-face" means the same as that term is defined in
12VAC30-130-5020.
"Individual service plan" or "ISP" means the same as the term
is defined in
12VAC30-130-5020.
"Progress notes" means individual-specific documentation that
contains the unique differences particular to the individual's circumstances,
treatment, and progress that is also signed and contemporaneously dated by the
provider's professional staff who have prepared the notes and are part of the
minimum documentation requirements that convey the individual's status, staff
intervention, and as appropriate, the individual's progress or lack of progress
toward goals and objectives in the ISP. The progress notes shall also include,
at a minimum, the name of the service rendered, the date of the service
rendered, the signature and credentials of the person who rendered the service,
the setting in which the service was rendered, and the amount of time or units
or hours required to deliver the service. The content of each progress note
shall corroborate the time or units billed for each rendered service. Progress
notes shall be documented for each service that is billed.
"Register" or "registration" means notifying the Department
of Medical Assistance Services or its contractor that an individual will be
receiving services that do not require service authorization, such as
outpatient services for substance use disorders or substance use case
management.
B. Utilization
review: substance use case management services.
1. The Medicaid-enrolled individual shall
have a substance use disorder diagnosis based on nationally recognized
criteria. Tobacco-related disorders or caffeine-related disorders and
non-substance-related disorders shall not be covered.
2. Reimbursement shall be provided only for
"active" case management. An active client for substance use case management
shall mean an individual for whom there is a current substance use individual
service plan (ISP) in effect that requires a minimum of two distinct substance
use case management activities being performed each calendar month and at a
minimum one face-to-face client contact at least every 90-calendar-day
period.
3. Billing can be submitted
for an active recipient only for months in which a minimum of two distinct
substance use case management activities are performed.
4. An ISP shall be completed within 30
calendar days of initiation of this service with the individual in a
person-centered manner and shall document the need for active substance use
case management before such case management services can be billed. The ISP
shall require a minimum of two distinct substance use case management
activities being performed each calendar month and a minimum of one
face-to-face client contact at least every 90 calendar days. The substance use
case manager shall review the ISP with the individual at least every 90
calendar days for the purpose of evaluating and updating the individual's
progress toward meeting the individualized service plan objectives.
5. The ISP shall be reviewed with the
individual present, and the outcome of the review shall be documented in the
individual's medical record.
C. Utilization review: substance use case
management services.
1. Utilization review
general requirements. Utilization reviews shall be conducted by DMAS or its
designated contractor. Reimbursement shall be provided only when there is an
active ISP, a minimum of two distinct substance use case management activities
are performed each calendar month, and there is a minimum of one face-to-face
client contact at least every 90-calendar-day period. Billing can be submitted
only for months in which a minimum of two distinct substance use case
management activities are performed within the calendar month.
2. In order to receive reimbursement,
providers shall register this service with the managed care organization or the
DMAS contractor, as required, within one business day of service initiation to
avoid duplication of services and to ensure informed and seamless care
coordination between substance use treatment and substance use case management
providers.
3. The Medicaid eligible
individual shall meet the nationally recognized criteria for a substance use
disorder with the exception of tobacco-related disorders or caffeine-related
disorders and non-substance-related disorders.
4. Substance use case management shall not be
billed for individuals in institutions for mental disease, except during the
month prior to discharge to allow for discharge planning, limited to two months
within a 12-month period. Substance use case management shall not be billed
concurrently with any other type of Medicaid reimbursed case management and
care coordination.
5. The ISP, as
defined in
12VAC30-130-5020, shall document
the need for substance use case management and be fully completed within 30
calendar days of initiation of the service, and the substance use case manager
shall review the ISP at least every 90 calendar days. Such reviews shall be
documented in the individual's medical record. If needed, a grace period will
be granted following the date of the last review. When the review is completed
in a grace period, the next subsequent review shall be scheduled 90 calendar
days from the date the review was initially due and not the date of actual
review.
6. The ISP shall be updated
and documented in the individual's medical record at least annually and as an
individual's needs change.
7. The
provider of substance use case management services shall be licensed by the
Department of Behavioral Health and Developmental Services as a provider of
substance use case management and credentialed by the DMAS contractor or the
managed care organization as a provider of substance use case management
services.
8. Progress notes, as
defined in subsection A of this section, shall be required to disclose the
extent of services provided and corroborate the units billed.
Statutory Authority: §§
32.1-324 and
32.1-325 of the Code of
Virginia.
