12 Va. Admin. Code § 30-60-185
Current through Register Vol. 41, No. 10, December 30, 2024
Section 12VAC30-60-185 - Utilization review of substance use case managementA. Definitions. The following words and terms when used in this section shall have the following meanings unless the context clearly indicates otherwise: "Face-to-face" means the same as that term is defined in 12VAC30-130-5020.
"Individual service plan" or "ISP" means the same as the term is defined in 12VAC30-130-5020.
"Progress notes" means individual-specific documentation that contains the unique differences particular to the individual's circumstances, treatment, and progress that is also signed and contemporaneously dated by the provider's professional staff who have prepared the notes and are part of the minimum documentation requirements that convey the individual's status, staff intervention, and as appropriate, the individual's progress or lack of progress toward goals and objectives in the ISP. The progress notes shall also include, at a minimum, the name of the service rendered, the date of the service rendered, the signature and credentials of the person who rendered the service, the setting in which the service was rendered, and the amount of time or units or hours required to deliver the service. The content of each progress note shall corroborate the time or units billed for each rendered service. Progress notes shall be documented for each service that is billed.
"Register" or "registration" means notifying the Department of Medical Assistance Services (DMAS) or its contractor that an individual will be receiving services that do not require service authorization, such as outpatient services for substance use disorders or substance use case management.
B. Utilization review: substance use case management services. 1. The Medicaid-enrolled individual shall have a substance use disorder diagnosis based on nationally recognized criteria. Tobacco-related disorders or caffeine-related disorders and non-substance-related disorders shall not be covered.2. Reimbursement shall be provided only for "active" case management. An active client for substance use case management shall mean an individual for whom there is a current substance use ISP in effect that requires a minimum of two distinct substance use case management activities being performed each calendar month and, at a minimum, one face-to-face client contact at least every 90-calendar-day period.3. Billing can be submitted for an active recipient only for months in which a minimum of two distinct substance use case management activities are performed.4. An ISP shall be completed within 30 calendar days of initiation of this service with the individual in a person-centered manner and shall document the need for active substance use case management before such case management services can be billed. The ISP shall require a minimum of two distinct substance use case management activities being performed each calendar month and a minimum of one face-to-face client contact at least every 90 calendar days. The substance use case manager shall review the ISP with the individual at least every 90 calendar days for the purpose of evaluating and updating the individual's progress toward meeting the individualized service plan objectives. Such reviews shall be documented in the individual's medical record.5. Reviews will be due by the end of month following the 90th calendar day from when the last review was completed. If needed, a grace period will be granted up to the last day of the next month. If the review was completed in a grace period, the next subsequent review shall be required within 90 calendar days from when the review was due and not the date of the actual review.6. The ISP shall be reviewed with the individual present.7. In order to receive reimbursement, providers shall register this service with the managed care organization or the DMAS contractor, as required, within one business day of service initiation to avoid duplication of services and to ensure informed and seamless care coordination between substance use treatment and substance use case management providers.8. Substance use case management shall not be billed concurrently with any other type of Medicaid reimbursed case management and care coordination.9. The ISP shall be updated and documented in the individual's medical record at least annually and as an individual's needs change.10. The provider of substance use case management services shall be licensed by the Department of Behavioral Health and Developmental Services as a provider of substance use case management and credentialed by the DMAS contractor or the managed care organization as a provider of substance use case management services.11. Progress notes, as defined in subsection A of this section, shall be required to disclose the extent of services provided and corroborate the units billed.12. Reimbursement is allowed for case management services for Medicaid-eligible individuals who are in institutions pursuant to 12VAC30-50-491.13. Utilization reviews shall be conducted by DMAS or its designated contractor.12 Va. Admin. Code § 30-60-185
Derived from Virginia Register Volume 26, Issue 8, eff. January 21, 2010; Amended, Virginia Register Volume 33, Issue 12, eff. 4/1/2017; Amended, Virginia Register Volume 36, Issue 11, eff. 3/5/2020; Amended, Virginia Register Volume 40, Issue 26, eff. 9/26/2024; Amended, Virginia Register Volume 41, Issue 7, eff. 1/2/2025.Statutory Authority: § 32.1-325 of the Code of Virginia.