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			24 text MINDFUL COMPLIANCE  / RULE LIBRARY
		25 button Search everything
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			27 text Search records, rules, terms, the briefing
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	29 container view
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			31 text RULE LIBRARY
			32 heading 90 rules, each with its source, Value: 1
				33 text 90 rules, each with its source
			34 text The rulebook behind everything in this hub: federal law, Virginia regulation, the DMAS manuals, the health plans and the clinical criteria. Every rule names its document, page and how sure we are.
			35 button Save the library (CSV)
		36 search text field (settable) Description: Search rules, ID: rq
		37 text LAYER
		38 checkbox All, Value: 1
		39 checkbox Federal law/regulation 19, Value: 0
		40 checkbox State regulation (Virginia) 16, Value: 0
		41 checkbox State Medicaid manual (DMAS) 46, Value: 0
		42 checkbox MCO contract / provider manual 3, Value: 0
		43 checkbox Payer clinical criteria 2, Value: 0
		44 checkbox Accreditation / case law / guidance 4, Value: 0
		45 text CERTAINTY
		46 checkbox All, Value: 1
		47 checkbox Read in the primary text, Value: 0
		48 checkbox Secondary: confirm, Value: 0
		49 checkbox General knowledge: confirm, Value: 0
		50 container rlist
			51 container rule-F-001
				52 text F-001 Federal law/regulation Primary text ALL Medicaid MCO
				53 button Copy a link to this rule
				54 heading Medical necessity definition, Value: 3
					55 text Medical necessity definition
				56 text An MCO's contract must define 'medically necessary services' in a way that is no more restrictive than the State Medicaid program, including quantitative and non-quantitative treatment limits set in state statute, regulation, State Plan and state policy.
				57 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					58 text Source, evidence and how the agent uses it
			59 container rule-F-002
				60 text F-002 Federal law/regulation Primary text ALL Medicaid MCO
				61 button Copy a link to this rule
				62 heading Who may deny, Value: 3
					63 text Who may deny
				64 text Any decision to deny a service authorization request, or to authorize less than requested, must be made by an individual with appropriate expertise in addressing the enrollee's medical, behavioral health, or LTSS needs.
				65 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					66 text Source, evidence and how the agent uses it
			67 container rule-F-003
				68 text F-003 Federal law/regulation Primary text ALL Medicaid MCO
				69 button Copy a link to this rule
				70 heading Authorization decision clocks, Value: 3
					71 text Authorization decision clocks
				72 text For rating periods starting on/after 1 Jan 2026, standard authorization decisions may not exceed 7 calendar days from receipt (14 days before that); expedited decisions no later than 72 hours when delay could seriously jeopardize life, health or ability to attain/maintain/regain maximum function. Either can be extended up to 14 days (requested by enrollee/provider, or justified by MCO need for information).
				73 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					74 text Source, evidence and how the agent uses it
			75 container rule-F-004
				76 text F-004 Federal law/regulation Primary text ALL Medicaid MCO
				77 button Copy a link to this rule
				78 heading Notice of denial must contain reasons and offer the criteria, Value: 3
					79 text Notice of denial must contain reasons and offer the criteria
				80 text The enrollee's written notice must state the determination, the reasons, and the right to free reasonable access to and copies of all relevant documents, including medical necessity criteria and any processes, strategies or evidentiary standards used to set coverage limits; plus appeal rights, expedited-appeal circumstances, and right to continued benefits. The MCO must also notify the requesting provider of a denial or partial approval.
				81 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					82 text Source, evidence and how the agent uses it
			83 container rule-F-005
				84 text F-005 Federal law/regulation Primary text ALL Medicaid MCO
				85 button Copy a link to this rule
				86 heading Late decision counts as denial, Value: 3
					87 text Late decision counts as denial
				88 text A service authorization decision not reached within the required timeframes constitutes a denial and is an adverse benefit determination; notice is due on the date the timeframe expires.
				89 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					90 text Source, evidence and how the agent uses it
			91 container rule-F-006
				92 text F-006 Federal law/regulation Primary text ALL Medicaid MCO
				93 button Copy a link to this rule
				94 heading Who can file an appeal and when, Value: 3
					95 text Who can file an appeal and when
				96 text An enrollee has 60 calendar days from the date on the adverse benefit determination notice to request an appeal with the plan (oral or written). The plan may have only one level of appeal. With the enrollee's written consent, and if state law permits, a provider or authorized representative may file the appeal, file a grievance or request a State fair hearing on the enrollee's behalf; BUT providers cannot request continuation of benefits.
				97 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					98 text Source, evidence and how the agent uses it
			99 container rule-F-007
				100 text F-007 Federal law/regulation Primary text ALL Medicaid MCO
				101 button Copy a link to this rule
				102 heading MCO appeal resolution clocks; fair hearing window, Value: 3
					103 text MCO appeal resolution clocks; fair hearing window
				104 text Standard appeal: resolve within 30 calendar days of receipt; expedited: within 72 hours; either extendable up to 14 days. If the plan misses notice/timing rules the enrollee is 'deemed to have exhausted' the plan appeal and can go to a State fair hearing. The enrollee must be given no less than 90 and no more than 120 calendar days from the MCO's notice of resolution to request a State fair hearing.
				105 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					106 text Source, evidence and how the agent uses it
			107 container rule-F-008
				108 text F-008 Federal law/regulation Primary text ALL Medicaid MCO
				109 button Copy a link to this rule
				110 heading Continuation of benefits while appealing, Value: 3
					111 text Continuation of benefits while appealing
				112 text Benefits must continue only if ALL are true: the appeal was filed timely; it concerns termination, suspension or reduction of previously authorized services; the services were ordered by an authorized provider; the period covered by the original authorization has NOT expired; and the enrollee timely requests continuation (within 10 calendar days of the notice or by the effective date of the action, whichever is later). If the plan wins, it may recover the cost of services furnished only because of this rule, per state policy and contract.
				113 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					114 text Source, evidence and how the agent uses it
			115 container rule-F-009
				116 text F-009 Federal law/regulation Primary text ALL
				117 button Copy a link to this rule
				118 heading Exclusion screening, Value: 3
					119 text Exclusion screening
				120 text The State Medicaid agency must check the LEIE (and EPLS/SAM) no less frequently than monthly for providers and persons with ownership/control. Virginia in turn requires its providers to screen all new and existing employees and contractors and search the OIG LEIE monthly (A-030).
				121 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					122 text Source, evidence and how the agent uses it
			123 container rule-F-010
				124 text F-010 Federal law/regulation Primary text ALL SUD services
				125 button Copy a link to this rule
				126 heading 42 CFR Part 2: who it covers, Value: 3
					127 text 42 CFR Part 2: who it covers
				128 text Part 2 applies to records that identify a patient as having or having had a substance use disorder, held by a federally assisted Part 2 program. 'Federally assisted' includes being a participating Medicare provider, holding certain federal authorizations (e.g., to conduct maintenance treatment or withdrawal management, or DEA registration used in SUD treatment), and being a recipient of federal financial assistance in any form. It limits using those records against the patient in criminal, civil, administrative or legislative proceedings without consent or court order.
				129 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					130 text Source, evidence and how the agent uses it
			131 container rule-F-011
				132 text F-011 Federal law/regulation Primary text ALL SUD services
				133 button Copy a link to this rule
				134 heading Part 2 qualified service organization (QSO), Value: 3
					135 text Part 2 qualified service organization (QSO)
				136 text A 'qualified service organization' provides services to a Part 2 program under a written agreement acknowledging it is bound by Part 2 and will resist judicial efforts to obtain patient-identifying information except as Part 2 permits. Definitions of treatment/payment/health care operations and business associate point to HIPAA (45 CFR 164.501, 160.103).
				137 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					138 text Source, evidence and how the agent uses it
			139 container rule-F-012
				140 text F-012 Federal law/regulation Secondary: confirm ALL SUD services
				141 button Copy a link to this rule
				142 heading Part 2 2024 rule: consent and compliance date, Value: 3
					143 text Part 2 2024 rule: consent and compliance date
				144 text The 2024 final rule lets a patient sign a single consent for all future uses and disclosures for treatment, payment and health care operations; recipients that are HIPAA covered entities or business associates may redisclose consistent with HIPAA (still not for use against the patient in proceedings). Enforcement now follows the HIPAA Enforcement Rule. Compliance was required by February 16, 2026.
				145 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					146 text Source, evidence and how the agent uses it
			147 container rule-F-013
				148 text F-013 Federal law/regulation General: confirm ALL
				149 button Copy a link to this rule
				150 heading HIPAA BAA, Value: 3
					151 text HIPAA BAA
				152 text A HIPAA covered entity must have a business associate agreement with any vendor that creates, receives, maintains or transmits PHI for it (45 CFR 164.502(e), 164.504(e)).
				153 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					154 text Source, evidence and how the agent uses it
			155 container rule-F-014
				156 text F-014 Federal law/regulation Secondary: confirm Commercial; Medicaid managed care
				157 button Copy a link to this rule
				158 heading Parity (MHPAEA), Value: 3
					159 text Parity (MHPAEA)
				160 text MHPAEA (2008) and its 2013 regulations remain in effect, plus the 2021 statutory requirement for comparative analyses of non-quantitative treatment limits. The 2024 final rule's new provisions are under a non-enforcement statement (May 15, 2025) pending litigation plus 18 months.
				161 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					162 text Source, evidence and how the agent uses it
			163 container rule-F-015
				164 text F-015 Federal law/regulation Secondary: confirm Medicaid/CHIP managed care
				165 button Copy a link to this rule
				166 heading CMS prior-authorization rule (CMS-0057-F), Value: 3
					167 text CMS prior-authorization rule (CMS-0057-F)
				168 text Operational prior-authorization requirements apply to Medicaid managed care from rating periods starting 1 Jan 2026 (shorter decision times; a specific reason for any denial); API requirements follow 1 Jan 2027; payers publish PA metrics.
				169 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					170 text Source, evidence and how the agent uses it
			171 container rule-F-016
				172 text F-016 Federal law/regulation Secondary: confirm ALL SUD
				173 button Copy a link to this rule
				174 heading Anti-kickback / patient brokering (EKRA), Value: 3
					175 text Anti-kickback / patient brokering (EKRA)
				176 text The Eliminating Kickbacks in Recovery Act (18 U.S.C. 220) makes it a federal crime to knowingly and willfully pay or receive remuneration for referring patients to a recovery home, clinical treatment facility or laboratory - regardless of payer. Also: the federal Anti-Kickback Statute for federal health programs.
				177 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					178 text Source, evidence and how the agent uses it
			179 container rule-F-017
				180 text F-017 Federal law/regulation Secondary: confirm ALL
				181 button Copy a link to this rule
				182 heading False Claims Act and overpayments, Value: 3
					183 text False Claims Act and overpayments
				184 text Submitting claims you know (or recklessly disregard) are false, including claims not supported by documentation, can create False Claims Act liability (treble damages plus per-claim penalties, about $14,308 to $28,619 per claim after the 2025 adjustment, per secondary sources). Identified overpayments must be reported and returned within 60 days (42 U.S.C. 1320a-7k(d)); CMS's rule effective Jan 1, 2025 says an overpayment is identified when you know of it (or recklessly disregard it) and suspends the 60 days for up to 180 days while a timely, good-faith investigation of related overpayments runs.
				185 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					186 text Source, evidence and how the agent uses it
			187 container rule-F-019
				188 text F-019 Federal law/regulation Primary text ALL Part 2 programs (SUD)
				189 button Copy a link to this rule
				190 heading Part 2 written consent: required elements, Value: 3
					191 text Part 2 written consent: required elements
				192 text A written consent (paper or electronic) must include: (1) patient name; (2) who is authorized to make the disclosure; (3) a specific, meaningful description of the information; (4) the recipient(s) (for a single TPO consent, 'my treating providers, health plans, third-party payers, and people helping to operate this program' or similar; if the recipient is a HIPAA covered entity or business associate, a statement that the record may be redisclosed as HIPAA permits, except for proceedings against the patient); (5) each purpose ('for treatment, payment, and health care operations' suffices for a TPO consent); (6) the right to revoke in writing and how; (7) an expiration date or event ('end of the treatment' or 'none' suffices for TPO); (8) patient signature (or authorized person for minors/incapacity); (9) date signed; (10) for TPO consents, statements about possible redisclosure no longer protected by Part 2 and the consequences of refusing to sign. SUD counseling notes need their own separate consent. A disclosure may not rely on a consent that is expired, facially deficient, known to be revoked or known to be false. Consent for use in civil, criminal, administrative or legislative proceedings cannot be combined with any other consent.
				193 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					194 text Source, evidence and how the agent uses it
			195 container rule-F-018
				196 text F-018 Federal law/regulation Primary text ALL Medicaid
				197 button Copy a link to this rule
				198 heading Utilization review is mandated by federal rules, Value: 3
					199 text Utilization review is mandated by federal rules
				200 text Federal regulations at 42 CFR Parts 455 and 456 require the Medicaid program to review and evaluate the care and services it pays for; DMAS and contractors run periodic utilization reviews and compliance reviews.
				201 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					202 text Source, evidence and how the agent uses it
			203 container rule-L-001
				204 text L-001 State regulation (Virginia) Primary text 2.1
				205 button Copy a link to this rule
				206 heading Level 2.1 (IOP) licensing definition - staffing, Value: 3
					207 text Level 2.1 (IOP) licensing definition - staffing
				208 text A DBHDS-licensed substance abuse intensive outpatient program must be staffed by an interdisciplinary team of appropriately credentialed addiction treatment professionals (counselors, psychologists, social workers, addiction-credentialed physicians); staff must be able to obtain/interpret biopsychosocial information, be trained in signs/symptoms of mental disorders and psychotropic medications and their interactions with substance use, and all clinical staff must be appropriately licensed/certified/registered.
				209 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					210 text Source, evidence and how the agent uses it
			211 container rule-L-002
				212 text L-002 State regulation (Virginia) Primary text 2.1
				213 button Copy a link to this rule
				214 heading Level 2.1 admission, Value: 3
					215 text Level 2.1 admission
				216 text Before admission to a substance abuse IOP, the individual must satisfy the provider's admission policies, which must at minimum require (1) a DSM substance use/addictive disorder diagnosis and (2) meeting Level 2.1 admission criteria of ASAM, including the specific criteria for adult and adolescent populations. The regulation does not itself mention a physical examination.
				217 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					218 text Source, evidence and how the agent uses it
			219 container rule-L-003
				220 text L-003 State regulation (Virginia) Primary text 2.5
				221 button Copy a link to this rule
				222 heading Level 2.5 (PHP) licensing definition, Value: 3
					223 text Level 2.5 (PHP) licensing definition
				224 text DBHDS rules for substance abuse partial hospitalization: interdisciplinary team (12VAC35-105-1680); no fewer than 20 hours of skilled treatment services per week in a structured program, with individual/group counseling, medication management, family therapy, peer support, education, recreational therapy, medical and nursing services as clinically appropriate, 24/7 emergency telephone services, and MAT available for OUD/AUD (-1690); admission requires DSM SUD dx + ASAM 2.5 admission criteria (-1700); discharge when goals met, different care needed, or challenges require alternative care (-1710); co-occurring enhanced programs (-1720).
				225 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					226 text Source, evidence and how the agent uses it
			227 container rule-L-001b
				228 text L-001b State regulation (Virginia) Primary text 2.1
				229 button Copy a link to this rule
				230 heading Level 2.1 program criteria (hours), Value: 3
					231 text Level 2.1 program criteria (hours)
				232 text 12VAC35-105-1740: the IOP must offer a minimum of three service hours per service day to achieve no fewer than nine and no more than 19 hours of programming per week in a structured environment (the ARTS manual adds the child/adolescent variant of two hours per day averaging 6-19 hours per week).
				233 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					234 text Source, evidence and how the agent uses it
			235 container rule-L-006
				236 text L-006 State regulation (Virginia) Primary text ALL Medicaid MCO members
				237 button Copy a link to this rule
				238 heading Virginia member grievances and appeals (managed care), Value: 3
					239 text Virginia member grievances and appeals (managed care)
				240 text MCOs must comply with 42 CFR 438 Subpart F. A provider or other representative WITH THE MEMBER'S WRITTEN CONSENT may act for the member in the MCO grievance/appeal or the DMAS appeals process. Internal appeal requests must be submitted within 60 days of the date of the notice of adverse benefit determination (oral requests must be followed up in writing unless expedited). Standard internal appeal decisions within 30 days of receipt (extendable up to 14 days); expedited decisions within 72 hours. The member must exhaust the MCO appeal, then may file with the DMAS Appeals Division within 120 days of receipt of the MCO's internal appeal decision. Continuation of benefits follows 42 CFR 438.420, and the member may be held liable for the cost if the hearing decision upholds the denial.
				241 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					242 text Source, evidence and how the agent uses it
			243 container rule-L-007
				244 text L-007 State regulation (Virginia) Primary text ALL DBHDS-licensed
				245 button Copy a link to this rule
				246 heading Human rights complaints, Value: 3
					247 text Human rights complaints
				248 text Each individual may complain that the provider violated their rights. On receiving a complaint the provider must: notify DBHDS no later than the next business day; have the director (or designee) contact the individual within 24 hours; start an impartial investigation or resolution no later than the next business day; protect the individual from retaliation; give the individual access to a human rights advocate; and report the director's decision and action plan within 10 working days, with written notice of the right to appeal to the local human rights committee. Allegations of abuse or neglect must be reported to DBHDS within 24 hours, with immediate protective steps and an investigation report within 10 working days. Complaint policies must be written and approved by DBHDS.
				249 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					250 text Source, evidence and how the agent uses it
			251 container rule-L-004
				252 text L-004 State regulation (Virginia) Primary text ALL DBHDS-licensed
				253 button Copy a link to this rule
				254 heading Serious incidents, Value: 3
					255 text Serious incidents
				256 text Level II and Level III serious incidents must be reported within 24 hours of discovery to DBHDS's web-based system and to designated individuals/authorized representatives; a root cause analysis is required within 30 days of discovery for Level II incidents and any Level III incidents.
				257 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					258 text Source, evidence and how the agent uses it
			259 container rule-L-005
				260 text L-005 State regulation (Virginia) Primary text ALL DBHDS-licensed
				261 button Copy a link to this rule
				262 heading Licensing corrective action plan, Value: 3
					263 text Licensing corrective action plan
				264 text After a licensing report, the provider must submit a corrective action plan within 15 business days (one extension of up to 10 business days if requested before the due date). The plan needs a description of corrective actions, completion dates and a responsible person. If DBHDS disapproves, the provider has 10 more business days to revise. Immediate corrective action is required where violations endanger individuals. A provisional license can be issued for inability to maintain compliance, threats to health/safety, multiple violations or failure to follow a prior plan.
				265 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					266 text Source, evidence and how the agent uses it
			267 container rule-L-008
				268 text L-008 State regulation (Virginia) Primary text ALL DBHDS-licensed
				269 button Copy a link to this rule
				270 heading Screening and admission record, Value: 3
					271 text Screening and admission record
				272 text For each initial contact and screening the provider must document: date of contact; name, age and gender; address and phone (if applicable); the reason the person is requesting services; and the disposition (referral elsewhere for assessment, waiting list, or admission). For people not admitted, keep that record for six months.
				273 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					274 text Source, evidence and how the agent uses it
			275 container rule-L-009
				276 text L-009 State regulation (Virginia) Primary text ALL DBHDS-licensed MH/SUD
				277 button Copy a link to this rule
				278 heading Initial and comprehensive assessment contents (licensing), Value: 3
					279 text Initial and comprehensive assessment contents (licensing)
				280 text Assessment starts before or at admission, with the individual (and authorized representative) taking part. The INITIAL assessment must cover immediate service, health and safety needs and at minimum: diagnosis; presenting needs (stated needs, psychiatric needs, support needs, onset and duration); current medical problems; current medications; current and past substance use including co-occurring disorders; and at-risk behavior to self and others. The COMPREHENSIVE assessment, due no later than 30 days after admission for MH/SUD services, must address: onset and duration; social, behavioral, developmental and family history and supports; cognitive functioning; employment, vocational and educational background; previous interventions and outcomes; financial resources and benefits; health history and current medical needs (allergies, recent complaints and conditions, nutrition, chronic conditions, communicable diseases, activity restrictions, special protocols, past serious illness/injury/hospitalization, household family illness, and substance use including prescription and nonprescription drugs); psychiatric and substance use issues and risk circumstances; history of abuse, neglect, sexual or domestic violence or trauma; legal status (authorized representative, commitment, representative payee); criminal charges, convictions, probation or parole; daily living skills; housing; ability to access services including transportation; and, where applicable, fall risk, communication needs and mobility equipment. Standardized state or federal tools may be used if they substantially meet these requirements.
				281 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					282 text Source, evidence and how the agent uses it
			283 container rule-L-010
				284 text L-010 State regulation (Virginia) Primary text ALL DBHDS-licensed MH/SUD
				285 button Copy a link to this rule
				286 heading ISP timing and informed choice (licensing), Value: 3
					287 text ISP timing and informed choice (licensing)
				288 text Initial person-centered ISP within 24 hours of admission (covering immediate service, health and safety needs) and in effect for the first 30 days for MH/SUD services; comprehensive ISP no later than 30 days after admission. Both must be based on the assessment with the individual's participation and informed choice: the proposed services, any alternative services, and the risks and benefits of each must be explained. If no alternatives exist, document that and the steps taken to look. Every ISP change must document that the individual participated, that options and risks/benefits were explained, and the reasons for the choice made.
				289 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					290 text Source, evidence and how the agent uses it
			291 container rule-L-011
				292 text L-011 State regulation (Virginia) Primary text ALL DBHDS-licensed
				293 button Copy a link to this rule
				294 heading ISP required contents and signatures (licensing), Value: 3
					295 text ISP required contents and signatures (licensing)
				296 text The comprehensive ISP must be based on needs, strengths, abilities, preferences, goals and natural supports from the assessment, and include: attainable goals, measurable objectives and specific strategies for each need; services, supports and frequency; the role of the individual and others; a communication plan if there are communication or language barriers; a behavioral support plan if applicable; a safety plan addressing identified risks (including fall risk); a crisis or relapse plan if applicable; target dates; who is responsible for coordinating services (including other agencies); recovery plans if applicable; and self-directed services if applicable. It must be signed and dated at least by the person responsible for implementing it and by the individual (or authorized representative), or document the attempts and the reason a signature could not be obtained. Goals should be written in the individual's own words whenever possible.
				297 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					298 text Source, evidence and how the agent uses it
			299 container rule-L-012
				300 text L-012 State regulation (Virginia) Primary text ALL DBHDS-licensed
				301 button Copy a link to this rule
				302 heading Transfer between services of the same provider, Value: 3
					303 text Transfer between services of the same provider
				304 text When an individual moves between services of the same provider (for example PHP to IOP), the receiving service must obtain: documentation of the individual's informed choice in the transfer decision and planning; family notification if appropriate; the signature of the person preparing the transfer summary and the transfer date; a written summary of progress, justification for transfer, and current strengths and needs; and the record including emergency medical information. The sending service keeps a copy of the face sheet and the progress summary and documents the transfer date and receiving service.
				305 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					306 text Source, evidence and how the agent uses it
			307 container rule-L-013
				308 text L-013 State regulation (Virginia) Primary text ALL DBHDS-licensed
				309 button Copy a link to this rule
				310 heading Discharge instructions and discharge summary (licensing), Value: 3
					311 text Discharge instructions and discharge summary (licensing)
				312 text Written discharge instructions to the individual (and authorized representative and successor provider as applicable) must include at least: medications and dosages; names, phone numbers and addresses of successor providers; current medical issues; and the individual's treating practitioners. Referrals must be arranged before the scheduled discharge date. A written discharge summary is due within 30 days of discharge with: reason for admission and discharge; the individual's participation in discharge planning; current functioning; recommended activities or referrals; status, location and arrangements for future services; progress on ISP goals and a summary of critical events; date of discharge and date the summary was written; and the preparer's signature.
				313 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					314 text Source, evidence and how the agent uses it
			315 container rule-L-014
				316 text L-014 State regulation (Virginia) Primary text Programs that administer or supervise medication
				317 button Copy a link to this rule
				318 heading Medication log and orders, Value: 3
					319 text Medication log and orders
				320 text The provider must keep a daily log of all medicines received and refused by each individual, identifying who administered it, the medication and dose given or refused, and the time. If the provider administers or supervises self-administration, a current medication order for every medication must be kept on site. Medication errors and adverse reactions follow 12VAC35-105-780.
				321 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					322 text Source, evidence and how the agent uses it
			323 container rule-L-015
				324 text L-015 State regulation (Virginia) Primary text ALL DBHDS-licensed
				325 button Copy a link to this rule
				326 heading Record entries: current, dated, authenticated, Value: 3
					327 text Record entries: current, dated, authenticated
				328 text The records management policy must cover confidentiality, access, storage, security, disaster recovery and disposition, consistent with Virginia Code 32.1-127.1:03, 42 USC 290dd, 42 CFR Part 2 and HIPAA. Entries in the individual's record must be current, dated and authenticated by the person making the entry; errors are corrected by striking through and initialing.
				329 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					330 text Source, evidence and how the agent uses it
			331 container rule-A-001
				332 text A-001 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				333 button Copy a link to this rule
				334 heading Which ASAM edition Virginia uses, Value: 3
					335 text Which ASAM edition Virginia uses
				336 text DMAS uses the ASAM Criteria THIRD edition (2013). The ARTS manual (revised 7/7/2025) says providers apply 'the most current version of the ASAM Criteria Third Edition, 2013' to determine level of care. The ARTS service authorization forms (updated 7/22/2025) use the third-edition dimension wording.
				337 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					338 text Source, evidence and how the agent uses it
			339 container rule-A-002
				340 text A-002 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				341 button Copy a link to this rule
				342 heading Service authorization required for 2.1 and 2.5, Value: 3
					343 text Service authorization required for 2.1 and 2.5
				344 text Service authorization is required for ASAM 2.1 and 2.5 (and 3.1 to 4.0); not for Level 1.0, OTP, OBAT, SBIRT. The medical record must corroborate what was told to the MCO to obtain the authorization.
				345 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					346 text Source, evidence and how the agent uses it
			347 container rule-A-003
				348 text A-003 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				349 button Copy a link to this rule
				350 heading Independent assessment of 2.1/2.5 requests, Value: 3
					351 text Independent assessment of 2.1/2.5 requests
				352 text MCOs and the FFS service authorization contractor must use an ARTS Care Coordinator (a licensed mental health professional), a licensed physician or medical director to perform an independent assessment of all requests for ARTS IOP and PHP (and residential/inpatient); length of treatment and service limits are set by them by applying ASAM.
				353 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					354 text Source, evidence and how the agent uses it
			355 container rule-A-010
				356 text A-010 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				357 button Copy a link to this rule
				358 heading Authorization response time, Value: 3
					359 text Authorization response time
				360 text MCOs and the DMAS FFS contractor must respond to 2.1 and 2.5 service authorization requests within 72 hours. If approved, they may reimburse retroactively so the member can start immediately.
				361 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					362 text Source, evidence and how the agent uses it
			363 container rule-A-011
				364 text A-011 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				365 button Copy a link to this rule
				366 heading When to submit initial and extension requests, Value: 3
					367 text When to submit initial and extension requests
				368 text DMAS-recommended timeframes: initial requests for ASAM 2.1 to 4.0 - 1 business day from service initiation, no more than 5 calendar days before service initiation. Extension requests - submitted BEFORE the current authorization ends but no more than 5 calendar days before its end date; if submitted after the current authorization ends, the extension begins on the day of receipt. (FFS contractor follows these; MCOs follow NCQA requirements.)
				369 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					370 text Source, evidence and how the agent uses it
			371 container rule-A-012
				372 text A-012 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				373 button Copy a link to this rule
				374 heading Forms that must be used, Value: 3
					375 text Forms that must be used
				376 text Providers must use the ARTS Service Authorization Review Form for initial requests and the ARTS Extension Review Form for extensions (MCOs and FFS contractor agreed to one form). FFS requests go through Acentra Health Atrezzo Next Generation (ANG), which since August 3, 2026 must be reached through the DMAS MES provider portal; incomplete questionnaires are administratively rejected.
				377 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					378 text Source, evidence and how the agent uses it
			379 container rule-A-013
				380 text A-013 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				381 button Copy a link to this rule
				382 heading What the initial authorization form asks for, Value: 3
					383 text What the initial authorization form asks for
				384 text Member/provider data; ICD-10 diagnosis codes (primary + co-occurring); estimated start and end dates; SUD treatment history across other ASAM levels in the past 12 months; medications; level and number of units requested (1 unit = 1 day); for each of the six dimensions, a level-matched rating AND a summary plus attachments of supporting documentation; for OUD, the plan to offer MAT (signature attests MAT was offered as standard of care and access is documented).
				385 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					386 text Source, evidence and how the agent uses it
			387 container rule-A-014
				388 text A-014 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				389 button Copy a link to this rule
				390 heading What the extension form asks for, Value: 3
					391 text What the extension form asks for
				392 text Existing authorization number and requested end date; last three alcohol/drug screens; ALL medications prescribed by the SUD provider with response; dimension 1-6 ratings with summaries and attachments; how the member is progressing under the current plan; revised treatment goals; a full discharge plan (discharge level of care, receiving agency, transition coordination done; MAT discharge plan incl. scheduled appointments for OUD); projected discharge date.
				393 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					394 text Source, evidence and how the agent uses it
			395 container rule-A-015
				396 text A-015 State Medicaid manual (DMAS) Primary text 2.1
				397 button Copy a link to this rule
				398 heading Level 2.1 service definition and units, Value: 3
					399 text Level 2.1 service definition and units
				400 text Structured program delivering a minimum of 3 service hours per service day for adults to average 9-19 hours/week (minimum 2 hours/day for children/adolescents to average 6-19). One unit = one day. A maximum average of 19 hours per week may be billed. If hours consistently exceed the standard range, the member should be evaluated for a more appropriate level. If a member does not complete the minimum hours on a day, document the deviation and reason in the record and notify the MCO/FFS contractor WEEKLY. Step-down below 9 hrs/wk (6 for adolescents) is allowed for 1-2 weeks before moving to Level 1, if approved by the MCO/FFS contractor and supported in the ISP.
				401 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					402 text Source, evidence and how the agent uses it
			403 container rule-A-016
				404 text A-016 State Medicaid manual (DMAS) Primary text 2.5
				405 button Copy a link to this rule
				406 heading Level 2.5 service definition and units, Value: 3
					407 text Level 2.5 service definition and units
				408 text Skilled treatment of at least 20 hours per week with at least 5 service hours per service day. One unit = one day. Procedure code S0201. Time not spent in skilled, clinically intensive treatment is not billable. Travel time excluded. Deviations from the 5-hour minimum must be documented and reported to the MCO weekly; if a member consistently deviates, reassess level of care. Medicaid allows a 1-2 week step-down transition to Level 2.1 or 1 when approved by the MCO and documented in the ISP.
				409 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					410 text Source, evidence and how the agent uses it
			411 container rule-A-017
				412 text A-017 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				413 button Copy a link to this rule
				414 heading Level 2.1 and 2.5 required service components, Value: 3
					415 text Level 2.1 and 2.5 required service components
				416 text 2.1: weekly-monitored components per the ISP (psychiatric and other individualized treatment planning; individual/family/group counseling; medication management; health literacy counseling; skill restoration; psychiatric/medical consultation available within 24 hours by phone and preferably within 72 hours in person/telemedicine; psychopharmacological consultation; addiction medication management on site or by referral; 24-hour emergency services when the program is not in session; MI/engagement; medical/psych/lab/toxicology by consultation or referral; infectious disease screening (HIV, hepatitis B/C, TB) if not screened in the past 12 months; access to buprenorphine, methadone, naltrexone for OUD/AUD). 2.5: similar, plus daily individual/group/family therapy, psychiatric and medical formal agreements with consults within 8 hours by phone or 48 hours in person/telemedicine, 24/7 emergency services, and daily skilled treatment, medication management and education groups on attendance days.
				417 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					418 text Source, evidence and how the agent uses it
			419 container rule-A-018
				420 text A-018 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				421 button Copy a link to this rule
				422 heading Group size, Value: 3
					423 text Group size
				424 text Group substance use counseling has a maximum of 12 individuals (or fewer depending on the clinical model); the limit may be exceeded based on the clinical determination of the CATP. CSACs and CSAC-supervisees may provide group counseling within scope.
				425 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					426 text Source, evidence and how the agent uses it
			427 container rule-A-019
				428 text A-019 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				429 button Copy a link to this rule
				430 heading No concurrent authorization, Value: 3
					431 text No concurrent authorization
				432 text 2.1 and 2.5 may not be authorized concurrently with each other, ASAM 3.3-4.0, or with mental health IOP/PHP, psychosocial rehabilitation, therapeutic day treatment, intensive in-home, therapeutic group home, community stabilization, RCSU, ACT, MST, FFT, PRTF or inpatient admission. A seven-day overlap with outpatient/community BH service may be allowed for care coordination. They may run alongside the pharmacotherapy component of Preferred OBAT/OTP (collaboration with the prescriber must be documented); OBAT/OTP visits, meds, labs, UDS may be billed separately, but counseling is part of the per diem.
				433 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					434 text Source, evidence and how the agent uses it
			435 container rule-A-020
				436 text A-020 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				437 button Copy a link to this rule
				438 heading Discharge and continuity requirements, Value: 3
					439 text Discharge and continuity requirements
				440 text Discharge when less intensive services may achieve stabilization, the member requests discharge, ceases to participate, or needs a higher level of care. Discharge planning must document realistic plans for continuity of MOUD with an in-network Medicaid provider. If there is a lapse in ASAM 1.0/2.1/2.5 services greater than 31 consecutive days with no communication, the provider shall discharge the individual. Reassess a member discharged more than 10 days.
				441 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					442 text Source, evidence and how the agent uses it
			443 container rule-A-021
				444 text A-021 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				445 button Copy a link to this rule
				446 heading Multidimensional assessment, Value: 3
					447 text Multidimensional assessment
				448 text Required for ASAM 2.1 to 4.0; face-to-face (in-person or telemedicine) by a CATP, or a CSAC/CSAC-supervisee with CATP sign-off. Required elements: HPI; family, developmental, substance use/addictive behavior, personal/social, legal, psychiatric and medical histories; spiritual history; review of systems; mental status exam; information available from current physical examination; formulation and diagnoses; survey of assets, vulnerabilities and supports; treatment recommendations. No required format. Services must start within 30 days of assessment completion, or the assessment must be redone. Update when needs change or when moving levels. The ARTS manual's definition list also names 'physical examination' among the elements.
				449 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					450 text Source, evidence and how the agent uses it
			451 container rule-A-022
				452 text A-022 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				453 button Copy a link to this rule
				454 heading Individual Service Plan (ISP) clocks, Value: 3
					455 text Individual Service Plan (ISP) clocks
				456 text Initial ISP within 24 hours of admission; comprehensive ISP within 30 calendar days of service initiation (required even if discharged earlier). ISP reviews follow A-049 (at least every 30 calendar days at 2.5, every 90 at 2.1). A separate Interdisciplinary Plan of Care (IPOC) applies only to Preferred OBAT and OTP programs, not to 2.1 or 2.5. ISP elements: needs, measurable goals/objectives, services and frequency with target dates, other agencies' roles, discharge plan; signed and dated by the CATP; adults sign (or document why not); minors: parent/guardian signature; documentation that choice of provider was offered; ISPs without all required elements are incomplete and don't meet reimbursement requirements.
				457 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					458 text Source, evidence and how the agent uses it
			459 container rule-A-023
				460 text A-023 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				461 button Copy a link to this rule
				462 heading Progress notes, Value: 3
					463 text Progress notes
				464 text Notes must be written, signed and dated at the time of service or within ONE business day; must include name/date of service, credentialed signature, time or units, circumstances, treatment and progress or lack of progress toward ISP goals, specific staff interventions, setting, and content that corroborates the time/units billed. DMAS will not reimburse dates of service whose notes are not individualized and case-specific; duplicated notes do not count; each note must show unique differences particular to the individual. No co-signature required for group notes/activities/call logs; therapy notes by residents/supervisees require co-signature by a licensed CATP.
				465 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					466 text Source, evidence and how the agent uses it
			467 container rule-A-024
				468 text A-024 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				469 button Copy a link to this rule
				470 heading Continued service criteria (from ASAM 3rd ed., quoted in the manual), Value: 3
					471 text Continued service criteria (from ASAM 3rd ed., quoted in the manual)
				472 text It is appropriate to retain the member at the present level if: (1) making progress but has not achieved ISP goals and continued treatment is needed to keep working toward them; or (2) not yet making progress but has capacity to resolve problems and is actively working on ISP goals, and continued treatment is medically necessary; and/or (3) new problems identified that are appropriately treated at this level (the least intensive/restrictive level at which they can be addressed). The provider must document readiness for discharge or need for transfer by each of the six dimensions.
				473 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					474 text Source, evidence and how the agent uses it
			475 container rule-A-025
				476 text A-025 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				477 button Copy a link to this rule
				478 heading Discharge/transfer criteria, Value: 3
					479 text Discharge/transfer criteria
				480 text Transfer or discharge is appropriate if: goals achieved; unable to resolve the problems despite ISP amendments (another level/type of service indicated); lack of capacity to resolve problems (another level indicated); or problems intensified/new problems requiring a more intensive level.
				481 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					482 text Source, evidence and how the agent uses it
			483 container rule-A-026
				484 text A-026 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				485 button Copy a link to this rule
				486 heading Utilization review/audit scope and sampling, Value: 3
					487 text Utilization review/audit scope and sampling
				488 text Reviews are conducted by DMAS, its contractor or the MCOs; may be on-site and UNANNOUNCED or desk reviews; a sample of billing is selected and expanded if excessive exceptions are found. They may include record review, observation, review of all policies and procedures and HR files, a program tour, and interviews with members/families. Reviewers examine, among other things: license and enrollment listing of each service and location (unlisted services/locations are subject to retraction); exclusion screening; appropriateness of admission and ASAM level and medical necessity; multidimensional assessment by proper credentials; staff licenses/qualifications; services consistent with ISP and invoices; staffing plans meeting DBHDS (12VAC35-105) and DMAS rules; service authorization corroborated by record; individualized (non-boilerplate) documentation; required program components delivered; duplication; billing matches documented time; PCP notification with Part 2-compliant releases.
				489 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					490 text Source, evidence and how the agent uses it
			491 container rule-A-027
				492 text A-027 State Medicaid manual (DMAS) Primary text ALL DMAS/MCO audits
				493 button Copy a link to this rule
				494 heading Audit response and appeal deadlines, Value: 3
					495 text Audit response and appeal deadlines
				496 text After a review, a written preliminary findings report is sent; the provider has 30 days from receipt to respond (request filed when date-stamped by the MCO/DMAS); a final report follows; if a plan of correction is offered and requested, 30 days from receipt of the final report to submit it. If the provider disagrees with the final findings it may request MCO reconsideration; before appealing an MCO audit to DMAS it must exhaust MCO reconsideration. DMAS appeals must be filed in writing within 30 days of the MCO's final reconsideration decision (or of DMAS's final overpayment letter); a notice is filed when date-stamped by the DMAS Appeals Division; documents received after 5:00 p.m. on the deadline day are untimely.
				497 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					498 text Source, evidence and how the agent uses it
			499 container rule-A-028
				500 text A-028 State Medicaid manual (DMAS) Primary text ALL DMAS/MCO audits and denied-payment disputes
				501 button Copy a link to this rule
				502 heading DMAS provider appeal mechanics, Value: 3
					503 text DMAS provider appeal mechanics
				504 text A provider appeal is a two-step process: informal appeal (written or in person at an Informal Fact-Finding Conference) then formal appeal. Informal appeal deadline for most issues: 30 days from RECEIPT of notice of the adverse action; no extensions by regulation; the appeal is filed only when date-stamped by the DMAS Appeals Division. Burden of proof is on the provider. A hold is placed on collection of an audit overpayment once an appeal is filed. Additional information must reach the appeals agent within 90 days of receipt of the appeal; an IFFC must be requested in writing and held within 90 days. Providers can ONLY appeal adverse actions for services already rendered or being rendered (not prospective denials). Filing: AIMS portal, appeals@dmas.virginia.gov, fax (804) 452-5454, or mail.
				505 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					506 text Source, evidence and how the agent uses it
			507 container rule-A-029
				508 text A-029 State Medicaid manual (DMAS) Primary text MCO denials (authorization and payment)
				509 button Copy a link to this rule
				510 heading Provider appeals of MCO decisions, Value: 3
					511 text Provider appeals of MCO decisions
				512 text Network and Medicaid-enrolled providers that rendered services can challenge an MCO's reconsideration decision to DMAS when they were (i) denied payment in whole or part, (ii) denied authorization for services rendered, or (iii) sent an overpayment demand. The MCO's internal reconsideration process is a prerequisite. DMAS's external decision binds the MCO. Providers whose network enrollment was denied/terminated by the MCO cannot use this path. The regulation I read does not state deadlines.
				513 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					514 text Source, evidence and how the agent uses it
			515 container rule-A-030
				516 text A-030 State Medicaid manual (DMAS) Primary text ALL
				517 button Copy a link to this rule
				518 heading Exclusion screening, Value: 3
					519 text Exclusion screening
				520 text Providers must screen all new and existing employees and contractors against the HHS-OIG exclusion list, search the LEIE monthly by name, and immediately report any exclusion found to DMAS. Payment cannot be made for items/services furnished by an excluded person when the provider knew or should have known; overpayment liability and civil monetary penalties may follow.
				521 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					522 text Source, evidence and how the agent uses it
			523 container rule-A-031
				524 text A-031 State Medicaid manual (DMAS) Primary text ALL
				525 button Copy a link to this rule
				526 heading License and enrollment must match services and locations, Value: 3
					527 text License and enrollment must match services and locations
				528 text If a provider lacks a full or conditional license, or its enrollment does not list each service and location, it is subject to retraction for all unlisted services/locations; entities with provisional licenses are not reimbursed by Medicaid. Providers must revalidate enrollment at least every 5 years. Credentialing requires the DBHDS license (by level of care) sent to the DMAS PRSS vendor and each MCO, plus site survey, insurance certificates, business license, W-9, ownership disclosure (CMS 1513), CLIA if applicable, CARF/Joint Commission accreditation as requested.
				529 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					530 text Source, evidence and how the agent uses it
			531 container rule-A-032
				532 text A-032 State Medicaid manual (DMAS) Primary text ALL
				533 button Copy a link to this rule
				534 heading Records and documentation basics, Value: 3
					535 text Records and documentation basics
				536 text Records of Medicaid-covered services must be retained not less than five years after date of service or discharge; all entries fully signed and dated (month/day/year) with the author's title; documentation must be contemporaneous (same day or within one business day); claims not adequately supported may be recovered; overpayments are subject to 12VAC30-80-130; any paid claim that cannot be verified at review is subject to retraction.
				537 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					538 text Source, evidence and how the agent uses it
			539 container rule-A-033
				540 text A-033 State Medicaid manual (DMAS) Primary text ALL ARTS
				541 button Copy a link to this rule
				542 heading Part 2 releases to notify PCP, Value: 3
					543 text Part 2 releases to notify PCP
				544 text Providers must request releases of information, and document steps to inform the member's primary care provider or pediatrician of SUD treatment with releases meeting 42 CFR Part 2; for case-managed members, send written monthly updates to the case manager and a written discharge summary to the PCP and case manager within 30 days of discontinuation.
				545 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					546 text Source, evidence and how the agent uses it
			547 container rule-A-034
				548 text A-034 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				549 button Copy a link to this rule
				550 heading Billing units and claim timing, Value: 3
					551 text Billing units and claim timing
				552 text Whole units only: do not round up partial units; billed time must match documented time. 2.1 = H0015 (Rev 0906 on UB); 2.5 = S0201 (Rev 0913 on UB); claim forms CMS-1500 or UB-04 for 2.1/2.5. Initial claim submission within 12 months of date of service (federal 42 CFR 447.45(d)); DMAS encourages billing within 30 days; MCOs may have shorter limits in their contracts. Providers must be credentialed with the member's MCO to bill.
				553 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					554 text Source, evidence and how the agent uses it
			555 container rule-A-035
				556 text A-035 State Medicaid manual (DMAS) Primary text MH-IOP
				557 button Copy a link to this rule
				558 heading MH-IOP: what it is, hours, components, documentation clocks, Value: 3
					559 text MH-IOP: what it is, hours, components, documentation clocks
				560 text Structured, time-limited program for adults and youth; available 9-19 hours/week (adults) or 6-19 (youth) and at least 3 days/week; the individual must take part in a minimum of 2 distinct service components daily and at least 2 hours of therapy per week; if minimums are not met, document the reason (and submit deviations with the next authorization request). Assessment by a licensed clinician at start (an assessment within the prior 30 days can count if reviewed/updated at admission); psychiatric evaluation by a physician/NP/PA within 72 HOURS of admission; updated assessment every 90 days of consecutive service; ISP reviewed at least every 30 calendar days; psychiatric medication management at least monthly; 24/7 individualized crisis plan. Billing: S9480 per diem, one unit per day, maximum 5 units per week; do not bill when the individual is not present; recreational outings are out of scope.
				561 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					562 text Source, evidence and how the agent uses it
			563 container rule-A-036
				564 text A-036 State Medicaid manual (DMAS) Primary text MH-IOP
				565 button Copy a link to this rule
				566 heading MH-IOP medical necessity criteria, Value: 3
					567 text MH-IOP medical necessity criteria
				568 text Admission - ALL of: ICD primary diagnosis that can be expected to respond to treatment; within 30 days persistent/increasing symptoms with decreased functioning AND transition from a higher level of care or failed lower levels; at risk of inpatient/residential/crisis stabilization/PHP (or stepping down) without immediate danger or need for 24-hour care; community natural supports who can ensure safety outside program hours; needs an intensive structured program with a multidisciplinary team; can reliably attend and participate; willing to recover in an ambulatory program; for youth, a family/caregiver resource. Continued stay - one of: still meets admission criteria; less intensive care inadequate; treatment still needed to reduce symptoms so a lower level can work; new symptoms with a revised ISP - AND all of: ISP shows likely response; progress documented or ISP modified; psychiatric evaluation shows medication options considered; natural supports engaged; care coordination and discharge planning ongoing since admission. If continued-stay criteria are not met, authorization may be extended up to 10 calendar days for transition. Discharge if criteria no longer met, goals met with aftercare, or non-participation despite engagement efforts. Exclusions: impairment solely from personality disorder/DD/ID; presenting issues primarily SUD (refer for ARTS).
				569 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					570 text Source, evidence and how the agent uses it
			571 container rule-A-037
				572 text A-037 State Medicaid manual (DMAS) Primary text MH-PHP
				573 button Copy a link to this rule
				574 heading MH-PHP: what it is, hours, components, documentation clocks, billing, Value: 3
					575 text MH-PHP: what it is, hours, components, documentation clocks, billing
				576 text Highly structured, short-term, non-residential program under physician direction; at least 4 hours/day, 5 days/week, minimum 20 hours/week; the individual must take part in at least 3 distinct covered components daily (2 if a Comprehensive Needs Assessment is one of them); daily therapy by a licensed clinician; at least 3 group skills-restoration sessions per week; 24/7 crisis plan; initial psychiatric evaluation within 48 HOURS of admission; ISP on day of admission and reviewed every 30 days; updated assessment every 90 days; psychiatric medication management at least WEEKLY. Deviations from 4 hours/day or 5 days/week: document the reason and tell the MCO/contractor at the next authorization review. Billing: H0035 per diem, one unit per day, four hours of covered components required; staffing ratio 1:12 adults, 1:5 youth; do not bill when the individual is absent. Team must include a board certified/eligible psychiatrist (child/adolescent psychiatrist for under 14) and a licensed mental health professional.
				577 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					578 text Source, evidence and how the agent uses it
			579 container rule-A-038
				580 text A-038 State Medicaid manual (DMAS) Primary text MH-PHP
				581 button Copy a link to this rule
				582 heading MH-PHP medical necessity criteria, Value: 3
					583 text MH-PHP medical necessity criteria
				584 text Admission - ALL of: ICD primary diagnosis expected to respond to treatment; within the last 14 days persistent/increasing symptoms with decreased functioning; at risk of inpatient/residential/crisis stabilization (or stepping down) without immediate danger or need for 24-hour care; natural supports for safety outside program hours; needs intensive structured program with on-site multidisciplinary team including psychiatric medication management; can reliably attend; severity cannot be safely or adequately addressed at a less intensive level; willing to recover in an ambulatory program; added eating-disorder criteria when applicable. Continued stay - one of four (still meets admission; less intensive care inadequate; treatment still needed so a lower level can work; new symptoms with revised ISP) AND all of: ISP shows likely response; progress or ISP modified; psychiatric evaluation shows medication options considered; natural supports engaged; care coordination and discharge planning since admission (plus eating-disorder items). If not met, up to 10 calendar days extension for transition; step-down below 20 hours/week allowed up to two weeks before discharge if planned in the ISP.
				585 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					586 text Source, evidence and how the agent uses it
			587 container rule-A-041
				588 text A-041 State Medicaid manual (DMAS) Primary text MH-IOP, MH-PHP
				589 button Copy a link to this rule
				590 heading MH-IOP / MH-PHP authorization requests and accreditation, Value: 3
					591 text MH-IOP / MH-PHP authorization requests and accreditation
				592 text Submit initial requests within one business day of admission and continued-stay requests by the requested start date; late requests begin on the date of receipt. Continued-stay packet at minimum: completed request form; initial assessment; current addendum (may be a progress note) describing new information, progress, interventions, rationale for continued service and evidence of medical necessity; updated ISP. If telemedicine is used, include the schedule of telemedicine vs. in-person, clinical evidence that telemedicine is appropriate, and how in-person needs will be met. Provider requirements: DMAS enrollment; DBHDS license for the specific program; MCO credentialing (MH-PHP, MH-IOP per Ch. II); AND Medicare certification OR accreditation by CARF, COA, DNV Healthcare or The Joint Commission (one year from DMAS enrollment to become Medicare-certified or two years to be accredited; documentation that the process has started must be submitted at enrollment).
				593 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					594 text Source, evidence and how the agent uses it
			595 container rule-A-042
				596 text A-042 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				597 button Copy a link to this rule
				598 heading Scale of the money: FFS per-diem rates (reference only), Value: 3
					599 text Scale of the money: FFS per-diem rates (reference only)
				600 text DMAS's reimbursement structure shows fee-for-service per-diem rates 'as of 7/1/22' of $250.00 per day for ASAM 2.1 (H0015, rev 0906) and $500.00 per day for ASAM 2.5 (S0201, rev 0913); 1 unit = 1 day; urgent requests reviewed within 72 hours with retroactive authorization. MCO-negotiated rates can differ, and these may have changed since 2022.
				601 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					602 text Source, evidence and how the agent uses it
			603 container rule-A-043
				604 text A-043 State Medicaid manual (DMAS) Primary text ALL Medicaid expansion adults
				605 button Copy a link to this rule
				606 heading 2027 Medicaid eligibility changes (work requirement, 6-month renewals, retro coverage), Value: 3
					607 text 2027 Medicaid eligibility changes (work requirement, 6-month renewals, retro coverage)
				608 text Starting January 2027, certain Medicaid Expansion adults ages 19-64 must show 80 hours/month of work, training, volunteering or half-time school (or about $580/month income) to keep coverage, unless exempt; exemptions include people with serious medical or mental health conditions and people with substance use disorders, among others. The same adults' coverage is reviewed every 6 months instead of 12. Retroactive coverage before the application date becomes more limited from January 1, 2027. DMAS tells providers to expect more frequent eligibility changes and verification requests.
				609 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					610 text Source, evidence and how the agent uses it
			611 container rule-A-038b
				612 text A-038b State Medicaid manual (DMAS) Secondary: confirm MH-IOP, MH-PHP
				613 button Copy a link to this rule
				614 heading MCO criteria vs. DMAS criteria (MH services), Value: 3
					615 text MCO criteria vs. DMAS criteria (MH services)
				616 text A search summary described the DMAS mental health manual as saying an MCO's medical necessity criteria 'shall not be more restrictive than the Department's criteria.' I searched the Appendix F and Chapter IV text I downloaded and did NOT find that sentence. The federal rule that says the same thing is F-001.
				617 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					618 text Source, evidence and how the agent uses it
			619 container rule-A-039
				620 text A-039 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				621 button Copy a link to this rule
				622 heading When provider and reviewer disagree (ARTS), Value: 3
					623 text When provider and reviewer disagree (ARTS)
				624 text The manual (citing ASAM's managed-care guidance) says that if the provider and the ARTS Care Coordinator/physician disagree about placement, identify the specific area of disagreement, and if no agreement is reached, providers may use the MCO appeal process documented in the authorization denial.
				625 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					626 text Source, evidence and how the agent uses it
			627 container rule-A-040
				628 text A-040 State Medicaid manual (DMAS) Primary text MH services (and BMOS skill-building)
				629 button Copy a link to this rule
				630 heading Virginia behavioral health redesign (July 2026), Value: 3
					631 text Virginia behavioral health redesign (July 2026)
				632 text DMAS is retiring legacy Medicaid behavioral health services (Intensive In-Home, Therapeutic Day Treatment, Mental Health Skill-Building, Psychosocial Rehabilitation; Targeted Case Management replaced by tiered case management) and launching new services on July 1, 2026, with implementation required to be complete by June 30, 2026 under the budget language; new DBHDS licensing (CPST) and later accreditation requirements. The 7/21/2025 update lists PHP/IOP as step-down/step-up partners of the new services and does not list them as retiring.
				633 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					634 text Source, evidence and how the agent uses it
			635 container rule-A-044
				636 text A-044 State Medicaid manual (DMAS) Primary text MH-IOP, MH-PHP
				637 button Copy a link to this rule
				638 heading Mental health progress note minimums (MH-IOP / MH-PHP), Value: 3
					639 text Mental health progress note minimums (MH-IOP / MH-PHP)
				640 text Progress notes must be written, signed and dated at the time of service or within one business day, be individualized, convey staff interventions and progress toward ISP goals, and be documented for each unit billed. At minimum: name of the service; date; dated signature and credentials of the person who rendered it; setting; and the time spent INCLUDING START AND END TIMES. Group notes must state the number of participants (group psychotherapy over 10 people needs documented clinical justification). Duplicated or non-individualized notes are not reimbursed and claims are retracted.
				641 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					642 text Source, evidence and how the agent uses it
			643 container rule-A-045
				644 text A-045 State Medicaid manual (DMAS) Primary text MH-IOP, MH-PHP
				645 button Copy a link to this rule
				646 heading Comprehensive Needs Assessment: 15 required elements (mental health), Value: 3
					647 text Comprehensive Needs Assessment: 15 required elements (mental health)
				648 text All 15 elements must be addressed for reimbursement: (1) presenting issue/reason for referral with duration, frequency and severity, stressors; (2) behavioral health history and hospitalizations, including family treatment history; (3) previous interventions, dates, providers and response; (4) medical profile: past/present problems, allergies, physical complaints, medications, fall risk as needed; (5) developmental history; (6) educational/vocational status; (7) current living situation, daily routine, housing, finances and benefits, family history and household members; (8) legal status: pending charges, court dates, probation, convictions, incarcerations; (9) drug and alcohol profile of the individual and family, type, frequency, duration, recovery efforts; (10) resources and strengths; (11) mental status profile with findings and tools used; (12) diagnosis with DSM code and description by the diagnosing LMHP; (13) clinical summary and formulation (causes, options, outcomes, barriers); (14) recommended care and treatment goals; (15) dated signatures of the LMHP/LMHP-R/LMHP-RP/LMHP-S. Valid only if face-to-face, signed and contemporaneously dated, all 15 present, each recommended service shown to be medically necessary, and kept current.
				649 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					650 text Source, evidence and how the agent uses it
			651 container rule-A-046
				652 text A-046 State Medicaid manual (DMAS) Primary text MH-IOP, MH-PHP
				653 button Copy a link to this rule
				654 heading MH-IOP / MH-PHP assessment, psychiatric evaluation and review clocks, Value: 3
					655 text MH-IOP / MH-PHP assessment, psychiatric evaluation and review clocks
				656 text At the start of services a LMHP (or R/RP/S), NP or PA completes an initial assessment consistent with the Comprehensive Needs Assessment, documenting diagnoses and how service needs match the level-of-care criteria (one done by the provider within 30 days before admission counts if reviewed and updated at admission). Psychiatric evaluation by a physician, NP or PA: within 72 hours of admission for MH-IOP, within 48 hours for MH-PHP (one within the prior 30 days counts if reviewed and updated at admission). Updated assessment every 90 days of consecutive service documenting continued medical necessity. Medication management by the psychiatric provider at least monthly (MH-IOP) or weekly (MH-PHP). ISP current throughout; MH-PHP initial ISP on the day of admission; ISP reviewed at least every 30 calendar days. An individualized crisis intervention plan accessible 24/7. Care coordination must look for additional recovery needs (housing, employment, food stability, mentoring, parenting supports), coordinate the ISP with any existing outpatient therapist, collaborate on transfer, referral and discharge, and collaborate with the primary care physician and other treating providers. MH-IOP: at least 2 distinct service components daily and at least 2 hours of therapy per week; if minimum hours or components are missed, document the deviation and reason and submit it with the next authorization request.
				657 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					658 text Source, evidence and how the agent uses it
			659 container rule-A-048
				660 text A-048 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				661 button Copy a link to this rule
				662 heading Assessment artifacts that must stay in the record (ARTS), Value: 3
					663 text Assessment artifacts that must stay in the record (ARTS)
				664 text The multidimensional assessment, the risk/severity rating and an immediate need profile must be kept in the member's record, organized by the six ASAM dimensions, and the level of care is based on them plus a DSM-5 substance-related diagnosis. CSACs/CSAC-supervisees cannot make diagnoses. Services must begin within 30 days of the assessment or it must be redone. ISP reviews must be added to the record within 7 days of the review date. When a member moves between levels in the same organization the assessment must support the new level and the ISP must be amended. The initial ISP must include the plan for assessing and offering MOUD (OUD) or AUD medications; if Dimension 1 or 2 shows medical concerns a physician/extender is consulted and named on the authorization form; if Dimension 3 shows mental health concerns a psychiatrist or psychiatric NP is consulted as clinically necessary and named with credentials. Naloxone co-prescribing with MOUD is required and must be part of discharge planning.
				665 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					666 text Source, evidence and how the agent uses it
			667 container rule-A-049
				668 text A-049 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				669 button Copy a link to this rule
				670 heading Comprehensive ISP contents and ISP reviews (ARTS), Value: 3
					671 text Comprehensive ISP contents and ISP reviews (ARTS)
				672 text The comprehensive ISP must: be developed with the member and appropriate collateral contacts (family, legally authorized representative, people the member will be released to); be based on the multidimensional assessment covering Dimensions 1-6 and on a diagnostic evaluation of medical, psychological, social, behavioral and developmental aspects; rest on a DSM-5 SUD diagnosis supported by valid and reliable assessment tools; describe prior treatment and testing; state measurable, evidence-based short- and long-term goals and objectives, family engagement activities, and community aftercare with target dates; for OUD/AUD, describe how pharmacotherapy (and naloxone) was assessed and offered; prescribe an integrated program of therapies; and describe transition and post-discharge coordination. Every ISP includes an individualized written discharge plan from the start of treatment, kept current. The ISP states which level(s) of care the member is in, and concurrent care (e.g., MOUD) is documented. A CATP signs off within three business days on an ISP developed by a CSAC/CSAC-supervisee. Reviews: at least every 30 calendar days at 2.5 and every 90 calendar days at 2.1 (and whenever needs change); an ISP not updated on time is 'outdated'. At 2.5, the 30-day review can be met by a progress note documenting that the plan and progress were discussed with the team and the member, any changes, and the member's response (member signature not required for that note). Family engagement interventions go on a progress note aligned to ISP goals; any deviation from the ISP needs a documented clinical justification. For co-occurring conditions, collaboration among all treating practitioners must be documented. Programs offering several levels need policies that differentiate the standards for each level.
				673 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					674 text Source, evidence and how the agent uses it
			675 container rule-A-050
				676 text A-050 State Medicaid manual (DMAS) Primary text ALL ARTS
				677 button Copy a link to this rule
				678 heading Diagnosis codes must match across record, authorization and claim, Value: 3
					679 text Diagnosis codes must match across record, authorization and claim
				680 text To be covered, ARTS services must meet medical necessity based on the multidimensional assessment, risk/severity rating and immediate need profile, and must be accurately reflected in the medical record and on claims by recognized diagnosis codes that support and are consistent with the services requested.
				681 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					682 text Source, evidence and how the agent uses it
			683 container rule-A-051
				684 text A-051 State Medicaid manual (DMAS) Primary text ALL ARTS
				685 button Copy a link to this rule
				686 heading Drug testing: how results are meant to be used, Value: 3
					687 text Drug testing: how results are meant to be used
				688 text Urine drug testing (presumptive screening or definitive testing) is used to monitor patients treated for SUD. Its use should be supportive and non-punitive; providers are encouraged to consider both positive and negative results in shaping current and future treatment. At 2.1/2.5, toxicology services are available through consultation or referral as indicated in the ISP, and the extension request lists the last three screens with date, result and substances.
				689 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					690 text Source, evidence and how the agent uses it
			691 container rule-A-052
				692 text A-052 State Medicaid manual (DMAS) Primary text ALL ARTS
				693 button Copy a link to this rule
				694 heading Service authorization rules updated 2026 (Appendix D), Value: 3
					695 text Service authorization rules updated 2026 (Appendix D)
				696 text DMAS, its prior-authorization contractor and the MCOs implemented CMS-0057-F from January 1, 2026: standard (non-urgent) authorization decisions within 7 calendar days (extendable up to 14 calendar days at the member's or provider's request, or when more information is needed and it is in the member's interest); expedited decisions within 72 hours; denial letters must state the specific reason and appeal rights. Fee-for-service requests are submitted in Atrezzo Next Generation (ANG), reached through the DMAS MES portal (required from August 3, 2026). Late fee-for-service requests are decided from the date received, and days not requested on time are denied. Before a DMAS appeal, a provider must exhaust Acentra Health's reconsideration: submitted in ANG within 30 calendar days of the initial determination letter, with added evidence; late reconsiderations are denied as untimely.
				697 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					698 text Source, evidence and how the agent uses it
			699 container rule-M-001
				700 text M-001 MCO contract / provider manual Primary text ALL
				701 button Copy a link to this rule
				702 heading Who the payers are (Virginia Medicaid), Value: 3
					703 text Who the payers are (Virginia Medicaid)
				704 text Virginia Medicaid managed care is Cardinal Care Managed Care (replaced Medallion 4.0 and CCC Plus, Oct 1 2023). DMAS's July 2025 authorization-form contact page lists: Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Humana Healthy Horizons in Virginia, Sentara Community Plan (and Sentara Community Plan Kaiser Permanente in some Northern Virginia localities) and UnitedHealthcare; fee-for-service ARTS authorizations go through Acentra Health (formerly KePRO) via the Atrezzo portal. Members previously on Molina were moved to Humana July 1, 2025.
				705 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					706 text Source, evidence and how the agent uses it
			707 container rule-M-002
				708 text M-002 MCO contract / provider manual Primary text ALL
				709 button Copy a link to this rule
				710 heading MCO rules beyond the state manual, Value: 3
					711 text MCO rules beyond the state manual
				712 text Each MCO's provider contract and provider manual binds the provider once signed, even where it goes beyond state rules. DMAS says MCOs conduct their own audits of members in managed care and providers must contact the MCO for its utilization review and control procedures. The service authorization timing recommendations in the ARTS manual bind the FFS contractor; the MCOs follow NCQA.
				713 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					714 text Source, evidence and how the agent uses it
			715 container rule-M-003
				716 text M-003 MCO contract / provider manual Secondary: confirm Anthem HealthKeepers Plus only (example)
				717 button Copy a link to this rule
				718 heading Example of an MCO's provider dispute windows, Value: 3
					719 text Example of an MCO's provider dispute windows
				720 text Anthem's Virginia provider news states claim payment reconsideration must be filed within 12 months of the explanation of payment, and claim payment appeals within 15 months of service or 180 days from the reconsideration decision. These are CLAIM payment windows, separate from clinical authorization appeals.
				721 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					722 text Source, evidence and how the agent uses it
			723 container rule-C-001
				724 text C-001 Payer clinical criteria Primary text 2.1, 2.5
				725 button Copy a link to this rule
				726 heading ASAM 3rd vs 4th edition vocabulary, Value: 3
					727 text ASAM 3rd vs 4th edition vocabulary
				728 text 4th edition (2023): level names include 2.1 Intensive Outpatient (IOP) and 2.5 High-Intensity Outpatient (HIOP) (3rd edition: Partial Hospitalization); dimensions are renamed/reordered: D1 Intoxication, Withdrawal and Addiction Medications; D2 Biomedical Conditions; D3 Psychiatric and Cognitive Conditions; D4 Substance Use-Related Risks; D5 Recovery Environment Interactions; D6 Person-Centered Considerations (not considered in the initial level-of-care recommendation). 3rd edition dimensions: acute intoxication/withdrawal potential; biomedical; emotional/behavioral/cognitive; readiness to change; relapse/continued use potential; recovery/living environment.
				729 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					730 text Source, evidence and how the agent uses it
			731 container rule-C-002
				732 text C-002 Payer clinical criteria General: confirm Mental health; some SUD
				733 button Copy a link to this rule
				734 heading Other criteria sets payers may use, Value: 3
					735 text Other criteria sets payers may use
				736 text Payers may apply their own policies or licensed criteria sets (InterQual, MCG) or LOCUS/CALOCUS/CASII for mental health level of care. Which one each Virginia MCO applies to MH-IOP/PHP and to ARTS 2.1/2.5 review is not in any document I have read.
				737 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					738 text Source, evidence and how the agent uses it
			739 container rule-X-001
				740 text X-001 Accreditation / case law / guidance Primary text ALL (if accredited)
				741 button Copy a link to this rule
				742 heading Accreditation standards, Value: 3
					743 text Accreditation standards
				744 text CARF or Joint Commission standards apply if the program is accredited (and MH-IOP requires accreditation; A-037). Auditors can hold a program to its own written policies in addition (layer 8).
				745 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					746 text Source, evidence and how the agent uses it
			747 container rule-X-002
				748 text X-002 Accreditation / case law / guidance Secondary: confirm Commercial plans (persuasive for Medicaid)
				749 button Copy a link to this rule
				750 heading Wit v. United Behavioral Health (commercial/ERISA), Value: 3
					751 text Wit v. United Behavioral Health (commercial/ERISA)
				752 text A federal court found UBH's internal level-of-care guidelines were inconsistent with generally accepted standards of care and overly restrictive (2019). The Ninth Circuit issued conflicting rulings in 2022-2023; per the Kennedy Forum tracker, the district court in Feb 2026 extended an injunction requiring UBH to use criteria reflecting generally accepted standards of care through Feb 2031, and reaffirmed a fiduciary-duty breach finding (Aug 2025).
				753 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					754 text Source, evidence and how the agent uses it
			755 container rule-X-003
				756 text X-003 Accreditation / case law / guidance Secondary: confirm Commercial, fully insured
				757 button Copy a link to this rule
				758 heading Commercial external review (Virginia), Value: 3
					759 text Commercial external review (Virginia)
				760 text For fully insured Virginia plans, after the plan's internal appeal, a consumer may request external review through the State Corporation Commission's Bureau of Insurance within 120 days of the notice of the right to external review; review is available for medical-necessity, level-of-care and setting denials.
				761 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					762 text Source, evidence and how the agent uses it
			763 container rule-X-004
				764 text X-004 Accreditation / case law / guidance Secondary: confirm AI deployment
				765 button Copy a link to this rule
				766 heading Virginia AI statutes (watch), Value: 3
					767 text Virginia AI statutes (watch)
				768 text HB 2094 (high-risk AI developer/deployer act) was vetoed in March 2025. SB 586 (2026), which would bar health carriers from relying exclusively on AI for adverse determinations, was continued to 2027 and is not law. This concerns payers' use of AI, not a provider's drafting assistant, but it is a direction-of-travel signal.
				769 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					770 text Source, evidence and how the agent uses it

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