Title of Regulation: 12VAC30-60. Standards Established and Methods Used to Assure High Quality Care (amending 12VAC30-60-5, 12VAC30-60-140).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Effective Dates: April 1, 2021, through September 30, 2022.

Agency Contact: Emily McClellan, Regulatory Supervisor, Policy Division, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-4300, FAX (804)786-1680, or email emily.mcclellan@dmas.virginia.gov.

Preamble:

Section 2.2-4011 of the Code of Virginia states that agencies may adopt emergency regulations in situations in which Virginia statutory law or the appropriation act requires that a regulation be effective in 280 days or less from its enactment, and the regulation is not exempt under the provisions of § 2.2-4006 A 4 of the Code of Virginia.

Item 303 X 1 of Chapter 2 of the 2018 Acts of Assembly and Item 303 X 1 of Chapter 854 of the 2019 Acts of Assembly, require the Department of Medical Assistance Services to make programmatic changes in the provision of community mental health services to ensure appropriate utilization and cost efficiency and to consider all available options including utilization review. The emergency action clarifies the documentation requirements for service authorization, including service authorization for community mental health and rehabilitative services.

12VAC30-60-5. Applicability of utilization review requirements.

A. In accordance with the requirements in 42 CFR Part 456 concerning utilization control of Medicaid services, the Department of Medical Assistance Services (DMAS) or its contractor shall implement utilization control measures, including service authorization requirements, post-payment reviews, quality management reviews, and other reviews to monitor quality and appropriate utilization of Medicaid services. These utilization requirements shall apply to all Medicaid covered services unless otherwise specified.

B. Some Medicaid covered services require an approved service authorization prior to service delivery in order to be considered for reimbursement to occur. Service authorization means the process to approve specific services for an enrolled Medicaid, FAMIS Plus, or FAMIS individual by a DMAS service authorization contractor prior to service delivery and reimbursement in order to validate that the service requested is medically necessary and meets DMAS and DMAS contractor criteria for reimbursement. Service authorization does not guarantee payment for the service.

1. To obtain service authorization, all providers' information supplied to the Department of Medical Assistance Services (DMAS) providers shall supply DMAS or its contractor shall be with information supporting the medical necessity for the requested service that is fully substantiated throughout documented in individuals' medical records.

C. 2. Providers shall be required to maintain documentation detailing all relevant information about the Medicaid individuals who are in the provider's care. Such documentation shall fully disclose the extent of services provided in order to support requests for service authorization and the provider's claims for reimbursement for services rendered. This documentation shall be written, signed, and dated at the time the services are rendered unless specified otherwise.

3. Continued authorization requests shall include the documentation requirements in subdivisions 1 and 2 of this subsection, as well as documentation of the individual's current status and the individual's progress, or lack of progress, toward goals and objectives in the ISP.

D. C. Providers shall maintain documentation that demonstrates that individuals providing services have the required qualifications established by DMAS, the Department of Health Professions (DHP), or the Department of Behavioral Health and Developmental Services (DBHDS).

E. DMAS, or its contractor, shall perform reviews of the utilization of all Medicaid covered services pursuant to 42 CFR 440.260 and 42 CFR Part 456.

F. D. DMAS or its contractor shall recover expenditures made for covered services when providers' documentation does not comport with standards specified in all applicable laws, regulations, and provider agreement requirements.

G. E. Providers who are determined not to be in compliance with DMAS applicable laws, regulations, or provider agreement requirements shall be subject to 12VAC30-80-130 for the repayment of those overpayments to DMAS.

H. Utilization review requirements specific to community mental health services and residential treatment services, including therapeutic group homes and psychiatric residential treatment facilities (PRTFs), as set out in 12VAC30-50-130 and 12VAC30-50-226, shall be as follows:

1. To apply to be reimbursed as a Medicaid provider, the required Department of Behavioral Health and Developmental Services (DBHDS) license shall be either a full, annual, triennial, or conditional license.

2. Health care entities with provisional licenses shall not be reimbursed as Medicaid providers.

3. Reimbursement shall not be permitted to health care entities that fail to enter into a provider contract with DMAS or its contractor for a service prior to rendering that service or fail to maintain a current Medicaid Provider Enrollment Agreement. If services are provided through a managed care organization (MCO), services shall not be reimbursed unless the provider is also enrolled with the MCO as a Medicaid provider

Payments shall not be permitted to health care entities that either hold provisional licenses or fail to enter into a provider contract with DMAS or its contractor for a service prior to rendering that service.

4. DMAS or its contractor shall apply a national standardized set of medical necessity criteria in use in the industry or an equivalent standard authorized in advance by DMAS. Services that fail to meet medical necessity criteria shall be denied service authorization.

5. Service providers shall maintain documentation to establish that services are rendered by individuals with appropriate qualifications and credentials, including proof of licensure or registration through DHP if applicable. Qualified mental health professional-eligibles, as defined by DBHDS, shall maintain documentation of supervision and of progress toward the requirements for DHP registration as a qualified mental health professional-child or progress toward the requirements for DHP registration as a qualified mental health professional-adult as those terms are defined by DBHDS.

12VAC30-60-140. Community mental health services.

A. In accordance with the requirements in 42 CFR Part 456 concerning utilization control of Medicaid services, the Department of Medical Assistance Services (DMAS) or its contractor shall implement utilization control measures for all community mental health services, including service authorization requirements, post-payment reviews, quality management reviews, and other reviews to monitor quality and appropriate utilization of Medicaid services. Utilization control measures for these services shall be performed in accordance with the general requirements of 12VAC30-60-5 and this section, as well as the more specific requirements contained in 12VAC30-60-61 and 12VAC30-60-143.

B. Service authorization.

1. Initial service authorization requests shall: (i) document how the individual's behaviors within the last 30 calendar days demonstrate that each of the medical necessity criteria for the service have been met, (ii) document how the individual's behaviors within the last 30 calendar days support the need for the number of service units and the span of dates requested, and (iii) demonstrate individualized and comprehensive treatment planning.

2. Continued authorization requests shall include the documentation requirements in subdivision 1 of this subsection, as well as documentation of the individual's current status and the individual's progress, or lack of progress, toward goals and objectives in the ISP.

C. 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) 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. D. 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.

5. To qualify as a Medicaid provider of community mental health services, the provider must have a full, annual, triennial, or conditional license from the Department of Behavioral Health and Developmental Services. Health care entities with provisional licenses shall not be reimbursed as Medicaid providers of community mental health services.

6. All providers must be enrolled with DMAS. If services are provided to a member enrolled in a Medicaid managed care organization (MCO), the provider shall also follow the MCO enrollment requirements. Once a provider has been enrolled, it shall maintain, and update periodically as DMAS and the MCO requires, current provider enrollment documentation for each Medicaid service that the provider offers.