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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 10. State Plan under Title XIX of the Social Security Act Medical Assistance Program; General Provisions
12/22/2024

12VAC30-10-530. Utilization and quality control.

A. A Statewide program of surveillance and utilization control has been implemented that safeguards against unnecessary or inappropriate use of Medicaid services available under this plan and against excess payments, and that assesses the quality of services. The requirements of 42 CFR Part 456 are met directly.

Quality review requirements described in § 1902(a)(30)(C) of the Act relating to services furnished by HMO's under contract are undertaken through contract with the PRO designated under 42 CFR Part 462.

B. The Medicaid agency meets the requirements of 42 CFR Part 456, Subpart C, for control of the utilization of inpatient hospital services. No waivers have been granted.

C. The Medicaid agency meets the requirements of 42 CFR Part 456, Subpart D, for control of utilization of inpatient services in mental hospitals.

No waivers have been granted.

D. The Medicaid agency meets the requirements of 42 CFR Part 456, Subpart E, for the control of utilization of skilled nursing facility services.

No waivers have been granted.

E. The Medicaid agency meets the requirements of 42 CFR Part 456, Subpart F, for control of the utilization of intermediate care facility services as provided through:

1. Direct review by personnel of the medical assistance unit of the state agency.

2. Personnel under contract to the medical assistance unit of the state agency.

The program will allow a maximum of 10 administrative days for placement and transfer from NF to community in order to make an orderly transfer or placement possible without potential harm or trauma to the patient in accordance with 42 CFR 456.4.

One of the semiannual utilization reviews required by 42 CFR 456.434(b)(1) for ICF/MR recipients will be conducted by the Virginia Department of Health as part of the inspection of care visit. The second utilization review will be conducted by personnel of the Medical Assistance unit of the state agency.

F. The Medicaid agency meets the requirements of § 1902(a)(30) of the Act for control of the assurance of quality furnished by each health maintenance organization under contract with the Medicaid agency. Independent, external quality reviews are performed annually by a Utilization and Quality Control Peer Review Organization designated under 42 CFR Part 462 that has a contract with the agency to perform those reviews.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Subsection A derived from VR460-01-46, eff. June 16, 1993; subsection B; am from VR460-01-47, eff. August 16, 1985; subsection C derived from VR460-01-48, eff. September 30, 1985; subsection D derived from VR460-01-49, eff. August 16, 1985; subsection E derived from VR460-01-50, eff. February 15, 1990; subsection F derived from VR460-01-50.1, eff. June 16, 1993; amended, Virginia Register Volume 13, Issue 5, eff. January 1, 1997.

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