Current through Register Vol. 41, No. 3, September 23, 2024
A. The Department
of Medical Assistance Services (DMAS) shall not reimburse for services which
are not authorized as follows:
1. DMAS shall
monitor, consistent with state law, the utilization of all inpatient hospital
services. All inpatient hospital stays shall be service authorized prior to
admission. Services rendered without such service authorization shall not be
covered, except as stated in subdivision 2 of this subsection.
2. If a provider has rendered inpatient
services to an individual who later is determined to be Medicaid eligible, the
provider shall be responsible for obtaining the required authorization prior to
billing DMAS for these services.
3.
Regardless of service authorization, DMAS shall review all claims which are
suspended for sterilization, hysterectomy, or abortion procedures for the
presence of the required federal and state forms prior to reimbursement. If the
forms are not attached to the bill and not properly completed, reimbursement
for the services rendered will be denied or reduced according to DMAS
policy.
B. To determine
that the DMAS enrolled hospital providers are in compliance with the
regulations governing hospital utilization control found in
42 CFR
456.50 through
456.145,
an annual audit will be conducted of each enrolled hospital. This audit can be
performed either on site or as a desk audit. The hospital shall make all
requested records available and shall provide an appropriate place for the
auditors to conduct such review if done on site. The audits shall consist of
review of the following:
1. Copy of the
general hospital's Utilization Management Plan to determine compliance with the
regulations found in
42 CFR
456.100 through
456.145.
2. List of current Utilization Management
Committee members and physician advisors to determine that the committee's
composition is as prescribed in the
42 CFR
456.105 through
456.106.
3. Verification of Utilization Management
Committee meetings since the last annual audit, including dates and lists of
attendees to determine that the committee is meeting according to their
utilization management meeting requirements.
4. One completed Medical Care Evaluation
Study to include objectives of the study, analysis of the results, and actions
taken, or recommendations made to determine compliance with the
42 CFR
456.141 through
456.145.
5. Topic of one ongoing Medical Care
Evaluation Study to determine the hospital is in compliance with the
42 CFR
456.145.
6. From a list of randomly selected paid
claims, the hospital must provide a copy of the physician admission
certification and written plan of care for each selected stay to determine the
hospital's compliance with the
42 CFR
456.60 and
456.80.
If any of the required documentation does not meet the requirements found in
the
42 CFR
456.60 through
456.80,
reimbursement may be retracted.
7.
The hospitals may appeal in accordance with the Administrative Process Act
(§ 9-6.14:1 et seq. of the Code of Virginia) any adverse decision
resulting from such audits which results in retraction of payment. The appeal
must be requested within 30 days of the date of the letter notifying the
hospital of the retraction.
Statutory Authority: §
32.1-325
of the Code of Virginia;
42 USC §
1396 et
seq.
