12VAC30-122-230: 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.