12 Va. Admin. Code § 30-122-230 - Utilization review and quality management review
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.
Notes
Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
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