{"data":{"id":"us-va/12vac30-120-400","jurisdiction":"us-va","citation":"12VAC30-120-400","heading":"Quality control and utilization review","body":"A. DMAS shall rigorously monitor the quality of care provided by the MCOs. DMAS  and the MCOs shall comply with (i) the contract; (ii) 42 CFR 438 Subpart E, entitled Quality Measurement and Improvement: External Quality Review; and (iii) the MCO standards identified in 42 CFR 438 Subpart D, entitled MCO, PIHP, and PAHP Standards. DMAS shall monitor the MCOs to determine  their compliance with the contract, 42 CFR Subpart A, and all other relevant sections of 42 CFR Part 438 (Managed Care) as follows:\n\n1.  If the MCO fails substantially to provide the medically necessary items and services required under law or under the contract to be provided to an enrolled recipient and the failure has adversely affected  or has substantial likelihood of adversely  affecting the individual.\n\n2.  If the MCO engages in any practice that discriminates against individuals on the basis of their health status or requirements for health care services, including expulsion or refusal to reenroll an individual, or any practice that could reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by § 1903(m) of the Social Security Act (42 USC §  1396(m)) by eligible individuals whose medical conditions or histories indicate a need for substantial future medical services.\n\n3.  If the MCO misrepresents or falsifies information that it furnishes, under § 1903(m) of the Social Security Act (42 USC § 1396b(m)) to CMS, DMAS, an individual, or any other entity.\n\n4.  If the MCO fails to comply with the requirements of 42 CFR 417.479(d) through 42 CFR 417.479(g) relating to physician incentive plans or fails to submit to DMAS its physician incentive plans as required or requested in 42 CFR 434.70.\n\n5.  If the MCO imposes on members premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program.\n\nB. DMAS shall ensure that data on performance and patient results are collected.\n\nC. DMAS shall ensure that quality outcomes information is provided to MCOs. DMAS shall ensure that changes  that are determined to be needed as a result of quality control or utilization review are made.","path":["Title 12. Health","Agency 30. Department of Medical Assistance Services","Chapter 120. Waivered Services","Part VI. Medallion Mandatory Managed Care"],"source_url":"https://law.lis.virginia.gov/admincode/title12/agency30/chapter120/section400/","current_through":"2026 Regular Session (effective July 1, 2026)","vintage":"","retrieved_at":"2026-09-14T04:51:08Z","sha256":"95f0d257701a5b1b5e87c35fb838dea755cbd28d8352c10b5efa2aabc1a09bad","source_id":"us-va-vac","stale":false,"prev":"us-va/12vac30-120-395","next":"us-va/12vac30-120-410"},"notice":"GroundRules: Original legal text. Not legal advice."}