“Technical” Correction for the Utilization Review of CMHRS
August 18, 2013Public comment is open through August 28th on the Townhall Website on the following:
12VAC30-60-140. Community mental health services. A. Utilization review general requirements.
On-site utilization Utilization reviews shall be conducted, at a minimum annually at for each enrolled provider, by the state Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) Medical Assistance Services (DMAS) or its contractor. During each on-site 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. The DMHMRSAS 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 12VAC30-50-220 12VAC30-50; and
4. Delivered services as documented are consistent with recipients’ Individual Service Plans, invoices submitted, and specified service limitations.