Browser tab: 2, Title: "Rule Library · Mindful Compliance", URL: "http://127.0.0.1:8767/resource/#rules".
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			30 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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			32 text RULE LIBRARY
			33 heading 90 rules, each with its source, Value: 1
				34 text 90 rules, each with its source
			35 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.
			36 button Save the library (CSV)
		37 search text field (settable) Description: Search rules, ID: rq
		38 text LAYER
		39 checkbox All, Value: 1
		40 checkbox Federal law/regulation 19, Value: 0
		41 checkbox State regulation (Virginia) 16, Value: 0
		42 checkbox State Medicaid manual (DMAS) 46, Value: 0
		43 checkbox MCO contract / provider manual 3, Value: 0
		44 checkbox Payer clinical criteria 2, Value: 0
		45 checkbox Accreditation / case law / guidance 4, Value: 0
		46 text CERTAINTY
		47 checkbox All, Value: 1
		48 checkbox Read in the primary text, Value: 0
		49 checkbox Secondary: confirm, Value: 0
		50 checkbox General knowledge: confirm, Value: 0
		51 container rlist
			52 container rule-F-001
				53 text F-001 Federal law/regulation Primary text ALL Medicaid MCO
				54 button Copy a link to this rule
				55 heading Medical necessity definition, Value: 3
					56 text Medical necessity definition
				57 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.
				58 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					59 text Source, evidence and how the agent uses it
			60 container rule-F-002
				61 text F-002 Federal law/regulation Primary text ALL Medicaid MCO
				62 button Copy a link to this rule
				63 heading Who may deny, Value: 3
					64 text Who may deny
				65 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.
				66 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					67 text Source, evidence and how the agent uses it
			68 container rule-F-003
				69 text F-003 Federal law/regulation Primary text ALL Medicaid MCO
				70 button Copy a link to this rule
				71 heading Authorization decision clocks, Value: 3
					72 text Authorization decision clocks
				73 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).
				74 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					75 text Source, evidence and how the agent uses it
			76 container rule-F-004
				77 text F-004 Federal law/regulation Primary text ALL Medicaid MCO
				78 button Copy a link to this rule
				79 heading Notice of denial must contain reasons and offer the criteria, Value: 3
					80 text Notice of denial must contain reasons and offer the criteria
				81 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.
				82 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					83 text Source, evidence and how the agent uses it
			84 container rule-F-005
				85 text F-005 Federal law/regulation Primary text ALL Medicaid MCO
				86 button Copy a link to this rule
				87 heading Late decision counts as denial, Value: 3
					88 text Late decision counts as denial
				89 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.
				90 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					91 text Source, evidence and how the agent uses it
			92 container rule-F-006
				93 text F-006 Federal law/regulation Primary text ALL Medicaid MCO
				94 button Copy a link to this rule
				95 heading Who can file an appeal and when, Value: 3
					96 text Who can file an appeal and when
				97 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.
				98 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					99 text Source, evidence and how the agent uses it
			100 container rule-F-007
				101 text F-007 Federal law/regulation Primary text ALL Medicaid MCO
				102 button Copy a link to this rule
				103 heading MCO appeal resolution clocks; fair hearing window, Value: 3
					104 text MCO appeal resolution clocks; fair hearing window
				105 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.
				106 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					107 text Source, evidence and how the agent uses it
			108 container rule-F-008
				109 text F-008 Federal law/regulation Primary text ALL Medicaid MCO
				110 button Copy a link to this rule
				111 heading Continuation of benefits while appealing, Value: 3
					112 text Continuation of benefits while appealing
				113 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.
				114 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					115 text Source, evidence and how the agent uses it
			116 container rule-F-009
				117 text F-009 Federal law/regulation Primary text ALL
				118 button Copy a link to this rule
				119 heading Exclusion screening, Value: 3
					120 text Exclusion screening
				121 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).
				122 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					123 text Source, evidence and how the agent uses it
			124 container rule-F-010
				125 text F-010 Federal law/regulation Primary text ALL SUD services
				126 button Copy a link to this rule
				127 heading 42 CFR Part 2: who it covers, Value: 3
					128 text 42 CFR Part 2: who it covers
				129 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.
				130 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					131 text Source, evidence and how the agent uses it
			132 container rule-F-011
				133 text F-011 Federal law/regulation Primary text ALL SUD services
				134 button Copy a link to this rule
				135 heading Part 2 qualified service organization (QSO), Value: 3
					136 text Part 2 qualified service organization (QSO)
				137 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).
				138 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					139 text Source, evidence and how the agent uses it
			140 container rule-F-012
				141 text F-012 Federal law/regulation Secondary: confirm ALL SUD services
				142 button Copy a link to this rule
				143 heading Part 2 2024 rule: consent and compliance date, Value: 3
					144 text Part 2 2024 rule: consent and compliance date
				145 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.
				146 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					147 text Source, evidence and how the agent uses it
			148 container rule-F-013
				149 text F-013 Federal law/regulation General: confirm ALL
				150 button Copy a link to this rule
				151 heading HIPAA BAA, Value: 3
					152 text HIPAA BAA
				153 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)).
				154 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					155 text Source, evidence and how the agent uses it
			156 container rule-F-014
				157 text F-014 Federal law/regulation Secondary: confirm Commercial; Medicaid managed care
				158 button Copy a link to this rule
				159 heading Parity (MHPAEA), Value: 3
					160 text Parity (MHPAEA)
				161 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.
				162 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					163 text Source, evidence and how the agent uses it
			164 container rule-F-015
				165 text F-015 Federal law/regulation Secondary: confirm Medicaid/CHIP managed care
				166 button Copy a link to this rule
				167 heading CMS prior-authorization rule (CMS-0057-F), Value: 3
					168 text CMS prior-authorization rule (CMS-0057-F)
				169 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.
				170 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					171 text Source, evidence and how the agent uses it
			172 container rule-F-016
				173 text F-016 Federal law/regulation Secondary: confirm ALL SUD
				174 button Copy a link to this rule
				175 heading Anti-kickback / patient brokering (EKRA), Value: 3
					176 text Anti-kickback / patient brokering (EKRA)
				177 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.
				178 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					179 text Source, evidence and how the agent uses it
			180 container rule-F-017
				181 text F-017 Federal law/regulation Secondary: confirm ALL
				182 button Copy a link to this rule
				183 heading False Claims Act and overpayments, Value: 3
					184 text False Claims Act and overpayments
				185 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.
				186 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					187 text Source, evidence and how the agent uses it
			188 container rule-F-019
				189 text F-019 Federal law/regulation Primary text ALL Part 2 programs (SUD)
				190 button Copy a link to this rule
				191 heading Part 2 written consent: required elements, Value: 3
					192 text Part 2 written consent: required elements
				193 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.
				194 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					195 text Source, evidence and how the agent uses it
			196 container rule-F-018
				197 text F-018 Federal law/regulation Primary text ALL Medicaid
				198 button Copy a link to this rule
				199 heading Utilization review is mandated by federal rules, Value: 3
					200 text Utilization review is mandated by federal rules
				201 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.
				202 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					203 text Source, evidence and how the agent uses it
			204 container rule-L-001
				205 text L-001 State regulation (Virginia) Primary text 2.1
				206 button Copy a link to this rule
				207 heading Level 2.1 (IOP) licensing definition - staffing, Value: 3
					208 text Level 2.1 (IOP) licensing definition - staffing
				209 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.
				210 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					211 text Source, evidence and how the agent uses it
			212 container rule-L-002
				213 text L-002 State regulation (Virginia) Primary text 2.1
				214 button Copy a link to this rule
				215 heading Level 2.1 admission, Value: 3
					216 text Level 2.1 admission
				217 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.
				218 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					219 text Source, evidence and how the agent uses it
			220 container rule-L-003
				221 text L-003 State regulation (Virginia) Primary text 2.5
				222 button Copy a link to this rule
				223 heading Level 2.5 (PHP) licensing definition, Value: 3
					224 text Level 2.5 (PHP) licensing definition
				225 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).
				226 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					227 text Source, evidence and how the agent uses it
			228 container rule-L-001b
				229 text L-001b State regulation (Virginia) Primary text 2.1
				230 button Copy a link to this rule
				231 heading Level 2.1 program criteria (hours), Value: 3
					232 text Level 2.1 program criteria (hours)
				233 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).
				234 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					235 text Source, evidence and how the agent uses it
			236 container rule-L-006
				237 text L-006 State regulation (Virginia) Primary text ALL Medicaid MCO members
				238 button Copy a link to this rule
				239 heading Virginia member grievances and appeals (managed care), Value: 3
					240 text Virginia member grievances and appeals (managed care)
				241 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.
				242 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					243 text Source, evidence and how the agent uses it
			244 container rule-L-007
				245 text L-007 State regulation (Virginia) Primary text ALL DBHDS-licensed
				246 button Copy a link to this rule
				247 heading Human rights complaints, Value: 3
					248 text Human rights complaints
				249 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.
				250 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					251 text Source, evidence and how the agent uses it
			252 container rule-L-004
				253 text L-004 State regulation (Virginia) Primary text ALL DBHDS-licensed
				254 button Copy a link to this rule
				255 heading Serious incidents, Value: 3
					256 text Serious incidents
				257 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.
				258 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					259 text Source, evidence and how the agent uses it
			260 container rule-L-005
				261 text L-005 State regulation (Virginia) Primary text ALL DBHDS-licensed
				262 button Copy a link to this rule
				263 heading Licensing corrective action plan, Value: 3
					264 text Licensing corrective action plan
				265 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.
				266 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					267 text Source, evidence and how the agent uses it
			268 container rule-L-008
				269 text L-008 State regulation (Virginia) Primary text ALL DBHDS-licensed
				270 button Copy a link to this rule
				271 heading Screening and admission record, Value: 3
					272 text Screening and admission record
				273 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.
				274 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					275 text Source, evidence and how the agent uses it
			276 container rule-L-009
				277 text L-009 State regulation (Virginia) Primary text ALL DBHDS-licensed MH/SUD
				278 button Copy a link to this rule
				279 heading Initial and comprehensive assessment contents (licensing), Value: 3
					280 text Initial and comprehensive assessment contents (licensing)
				281 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.
				282 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					283 text Source, evidence and how the agent uses it
			284 container rule-L-010
				285 text L-010 State regulation (Virginia) Primary text ALL DBHDS-licensed MH/SUD
				286 button Copy a link to this rule
				287 heading ISP timing and informed choice (licensing), Value: 3
					288 text ISP timing and informed choice (licensing)
				289 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.
				290 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					291 text Source, evidence and how the agent uses it
			292 container rule-L-011
				293 text L-011 State regulation (Virginia) Primary text ALL DBHDS-licensed
				294 button Copy a link to this rule
				295 heading ISP required contents and signatures (licensing), Value: 3
					296 text ISP required contents and signatures (licensing)
				297 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.
				298 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					299 text Source, evidence and how the agent uses it
			300 container rule-L-012
				301 text L-012 State regulation (Virginia) Primary text ALL DBHDS-licensed
				302 button Copy a link to this rule
				303 heading Transfer between services of the same provider, Value: 3
					304 text Transfer between services of the same provider
				305 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.
				306 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					307 text Source, evidence and how the agent uses it
			308 container rule-L-013
				309 text L-013 State regulation (Virginia) Primary text ALL DBHDS-licensed
				310 button Copy a link to this rule
				311 heading Discharge instructions and discharge summary (licensing), Value: 3
					312 text Discharge instructions and discharge summary (licensing)
				313 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.
				314 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					315 text Source, evidence and how the agent uses it
			316 container rule-L-014
				317 text L-014 State regulation (Virginia) Primary text Programs that administer or supervise medication
				318 button Copy a link to this rule
				319 heading Medication log and orders, Value: 3
					320 text Medication log and orders
				321 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.
				322 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					323 text Source, evidence and how the agent uses it
			324 container rule-L-015
				325 text L-015 State regulation (Virginia) Primary text ALL DBHDS-licensed
				326 button Copy a link to this rule
				327 heading Record entries: current, dated, authenticated, Value: 3
					328 text Record entries: current, dated, authenticated
				329 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.
				330 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					331 text Source, evidence and how the agent uses it
			332 container rule-A-001
				333 text A-001 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				334 button Copy a link to this rule
				335 heading Which ASAM edition Virginia uses, Value: 3
					336 text Which ASAM edition Virginia uses
				337 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.
				338 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					339 text Source, evidence and how the agent uses it
			340 container rule-A-002
				341 text A-002 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				342 button Copy a link to this rule
				343 heading Service authorization required for 2.1 and 2.5, Value: 3
					344 text Service authorization required for 2.1 and 2.5
				345 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.
				346 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					347 text Source, evidence and how the agent uses it
			348 container rule-A-003
				349 text A-003 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				350 button Copy a link to this rule
				351 heading Independent assessment of 2.1/2.5 requests, Value: 3
					352 text Independent assessment of 2.1/2.5 requests
				353 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.
				354 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					355 text Source, evidence and how the agent uses it
			356 container rule-A-010
				357 text A-010 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				358 button Copy a link to this rule
				359 heading Authorization response time, Value: 3
					360 text Authorization response time
				361 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.
				362 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					363 text Source, evidence and how the agent uses it
			364 container rule-A-011
				365 text A-011 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				366 button Copy a link to this rule
				367 heading When to submit initial and extension requests, Value: 3
					368 text When to submit initial and extension requests
				369 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.)
				370 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					371 text Source, evidence and how the agent uses it
			372 container rule-A-012
				373 text A-012 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				374 button Copy a link to this rule
				375 heading Forms that must be used, Value: 3
					376 text Forms that must be used
				377 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.
				378 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					379 text Source, evidence and how the agent uses it
			380 container rule-A-013
				381 text A-013 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				382 button Copy a link to this rule
				383 heading What the initial authorization form asks for, Value: 3
					384 text What the initial authorization form asks for
				385 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).
				386 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					387 text Source, evidence and how the agent uses it
			388 container rule-A-014
				389 text A-014 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				390 button Copy a link to this rule
				391 heading What the extension form asks for, Value: 3
					392 text What the extension form asks for
				393 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.
				394 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					395 text Source, evidence and how the agent uses it
			396 container rule-A-015
				397 text A-015 State Medicaid manual (DMAS) Primary text 2.1
				398 button Copy a link to this rule
				399 heading Level 2.1 service definition and units, Value: 3
					400 text Level 2.1 service definition and units
				401 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.
				402 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					403 text Source, evidence and how the agent uses it
			404 container rule-A-016
				405 text A-016 State Medicaid manual (DMAS) Primary text 2.5
				406 button Copy a link to this rule
				407 heading Level 2.5 service definition and units, Value: 3
					408 text Level 2.5 service definition and units
				409 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.
				410 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					411 text Source, evidence and how the agent uses it
			412 container rule-A-017
				413 text A-017 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				414 button Copy a link to this rule
				415 heading Level 2.1 and 2.5 required service components, Value: 3
					416 text Level 2.1 and 2.5 required service components
				417 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.
				418 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					419 text Source, evidence and how the agent uses it
			420 container rule-A-018
				421 text A-018 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				422 button Copy a link to this rule
				423 heading Group size, Value: 3
					424 text Group size
				425 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.
				426 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					427 text Source, evidence and how the agent uses it
			428 container rule-A-019
				429 text A-019 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				430 button Copy a link to this rule
				431 heading No concurrent authorization, Value: 3
					432 text No concurrent authorization
				433 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.
				434 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					435 text Source, evidence and how the agent uses it
			436 container rule-A-020
				437 text A-020 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				438 button Copy a link to this rule
				439 heading Discharge and continuity requirements, Value: 3
					440 text Discharge and continuity requirements
				441 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.
				442 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					443 text Source, evidence and how the agent uses it
			444 container rule-A-021
				445 text A-021 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				446 button Copy a link to this rule
				447 heading Multidimensional assessment, Value: 3
					448 text Multidimensional assessment
				449 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.
				450 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					451 text Source, evidence and how the agent uses it
			452 container rule-A-022
				453 text A-022 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				454 button Copy a link to this rule
				455 heading Individual Service Plan (ISP) clocks, Value: 3
					456 text Individual Service Plan (ISP) clocks
				457 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.
				458 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					459 text Source, evidence and how the agent uses it
			460 container rule-A-023
				461 text A-023 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				462 button Copy a link to this rule
				463 heading Progress notes, Value: 3
					464 text Progress notes
				465 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.
				466 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					467 text Source, evidence and how the agent uses it
			468 container rule-A-024
				469 text A-024 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				470 button Copy a link to this rule
				471 heading Continued service criteria (from ASAM 3rd ed., quoted in the manual), Value: 3
					472 text Continued service criteria (from ASAM 3rd ed., quoted in the manual)
				473 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.
				474 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					475 text Source, evidence and how the agent uses it
			476 container rule-A-025
				477 text A-025 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				478 button Copy a link to this rule
				479 heading Discharge/transfer criteria, Value: 3
					480 text Discharge/transfer criteria
				481 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.
				482 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					483 text Source, evidence and how the agent uses it
			484 container rule-A-026
				485 text A-026 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				486 button Copy a link to this rule
				487 heading Utilization review/audit scope and sampling, Value: 3
					488 text Utilization review/audit scope and sampling
				489 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.
				490 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					491 text Source, evidence and how the agent uses it
			492 container rule-A-027
				493 text A-027 State Medicaid manual (DMAS) Primary text ALL DMAS/MCO audits
				494 button Copy a link to this rule
				495 heading Audit response and appeal deadlines, Value: 3
					496 text Audit response and appeal deadlines
				497 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.
				498 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					499 text Source, evidence and how the agent uses it
			500 container rule-A-028
				501 text A-028 State Medicaid manual (DMAS) Primary text ALL DMAS/MCO audits and denied-payment disputes
				502 button Copy a link to this rule
				503 heading DMAS provider appeal mechanics, Value: 3
					504 text DMAS provider appeal mechanics
				505 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.
				506 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					507 text Source, evidence and how the agent uses it
			508 container rule-A-029
				509 text A-029 State Medicaid manual (DMAS) Primary text MCO denials (authorization and payment)
				510 button Copy a link to this rule
				511 heading Provider appeals of MCO decisions, Value: 3
					512 text Provider appeals of MCO decisions
				513 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.
				514 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					515 text Source, evidence and how the agent uses it
			516 container rule-A-030
				517 text A-030 State Medicaid manual (DMAS) Primary text ALL
				518 button Copy a link to this rule
				519 heading Exclusion screening, Value: 3
					520 text Exclusion screening
				521 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.
				522 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					523 text Source, evidence and how the agent uses it
			524 container rule-A-031
				525 text A-031 State Medicaid manual (DMAS) Primary text ALL
				526 button Copy a link to this rule
				527 heading License and enrollment must match services and locations, Value: 3
					528 text License and enrollment must match services and locations
				529 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.
				530 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					531 text Source, evidence and how the agent uses it
			532 container rule-A-032
				533 text A-032 State Medicaid manual (DMAS) Primary text ALL
				534 button Copy a link to this rule
				535 heading Records and documentation basics, Value: 3
					536 text Records and documentation basics
				537 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.
				538 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					539 text Source, evidence and how the agent uses it
			540 container rule-A-033
				541 text A-033 State Medicaid manual (DMAS) Primary text ALL ARTS
				542 button Copy a link to this rule
				543 heading Part 2 releases to notify PCP, Value: 3
					544 text Part 2 releases to notify PCP
				545 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.
				546 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					547 text Source, evidence and how the agent uses it
			548 container rule-A-034
				549 text A-034 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				550 button Copy a link to this rule
				551 heading Billing units and claim timing, Value: 3
					552 text Billing units and claim timing
				553 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.
				554 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					555 text Source, evidence and how the agent uses it
			556 container rule-A-035
				557 text A-035 State Medicaid manual (DMAS) Primary text MH-IOP
				558 button Copy a link to this rule
				559 heading MH-IOP: what it is, hours, components, documentation clocks, Value: 3
					560 text MH-IOP: what it is, hours, components, documentation clocks
				561 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.
				562 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					563 text Source, evidence and how the agent uses it
			564 container rule-A-036
				565 text A-036 State Medicaid manual (DMAS) Primary text MH-IOP
				566 button Copy a link to this rule
				567 heading MH-IOP medical necessity criteria, Value: 3
					568 text MH-IOP medical necessity criteria
				569 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).
				570 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					571 text Source, evidence and how the agent uses it
			572 container rule-A-037
				573 text A-037 State Medicaid manual (DMAS) Primary text MH-PHP
				574 button Copy a link to this rule
				575 heading MH-PHP: what it is, hours, components, documentation clocks, billing, Value: 3
					576 text MH-PHP: what it is, hours, components, documentation clocks, billing
				577 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.
				578 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					579 text Source, evidence and how the agent uses it
			580 container rule-A-038
				581 text A-038 State Medicaid manual (DMAS) Primary text MH-PHP
				582 button Copy a link to this rule
				583 heading MH-PHP medical necessity criteria, Value: 3
					584 text MH-PHP medical necessity criteria
				585 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.
				586 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					587 text Source, evidence and how the agent uses it
			588 container rule-A-041
				589 text A-041 State Medicaid manual (DMAS) Primary text MH-IOP, MH-PHP
				590 button Copy a link to this rule
				591 heading MH-IOP / MH-PHP authorization requests and accreditation, Value: 3
					592 text MH-IOP / MH-PHP authorization requests and accreditation
				593 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).
				594 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					595 text Source, evidence and how the agent uses it
			596 container rule-A-042
				597 text A-042 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				598 button Copy a link to this rule
				599 heading Scale of the money: FFS per-diem rates (reference only), Value: 3
					600 text Scale of the money: FFS per-diem rates (reference only)
				601 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.
				602 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					603 text Source, evidence and how the agent uses it
			604 container rule-A-043
				605 text A-043 State Medicaid manual (DMAS) Primary text ALL Medicaid expansion adults
				606 button Copy a link to this rule
				607 heading 2027 Medicaid eligibility changes (work requirement, 6-month renewals, retro coverage), Value: 3
					608 text 2027 Medicaid eligibility changes (work requirement, 6-month renewals, retro coverage)
				609 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.
				610 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					611 text Source, evidence and how the agent uses it
			612 container rule-A-038b
				613 text A-038b State Medicaid manual (DMAS) Secondary: confirm MH-IOP, MH-PHP
				614 button Copy a link to this rule
				615 heading MCO criteria vs. DMAS criteria (MH services), Value: 3
					616 text MCO criteria vs. DMAS criteria (MH services)
				617 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.
				618 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					619 text Source, evidence and how the agent uses it
			620 container rule-A-039
				621 text A-039 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				622 button Copy a link to this rule
				623 heading When provider and reviewer disagree (ARTS), Value: 3
					624 text When provider and reviewer disagree (ARTS)
				625 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.
				626 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					627 text Source, evidence and how the agent uses it
			628 container rule-A-040
				629 text A-040 State Medicaid manual (DMAS) Primary text MH services (and BMOS skill-building)
				630 button Copy a link to this rule
				631 heading Virginia behavioral health redesign (July 2026), Value: 3
					632 text Virginia behavioral health redesign (July 2026)
				633 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.
				634 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					635 text Source, evidence and how the agent uses it
			636 container rule-A-044
				637 text A-044 State Medicaid manual (DMAS) Primary text MH-IOP, MH-PHP
				638 button Copy a link to this rule
				639 heading Mental health progress note minimums (MH-IOP / MH-PHP), Value: 3
					640 text Mental health progress note minimums (MH-IOP / MH-PHP)
				641 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.
				642 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					643 text Source, evidence and how the agent uses it
			644 container rule-A-045
				645 text A-045 State Medicaid manual (DMAS) Primary text MH-IOP, MH-PHP
				646 button Copy a link to this rule
				647 heading Comprehensive Needs Assessment: 15 required elements (mental health), Value: 3
					648 text Comprehensive Needs Assessment: 15 required elements (mental health)
				649 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.
				650 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					651 text Source, evidence and how the agent uses it
			652 container rule-A-046
				653 text A-046 State Medicaid manual (DMAS) Primary text MH-IOP, MH-PHP
				654 button Copy a link to this rule
				655 heading MH-IOP / MH-PHP assessment, psychiatric evaluation and review clocks, Value: 3
					656 text MH-IOP / MH-PHP assessment, psychiatric evaluation and review clocks
				657 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.
				658 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					659 text Source, evidence and how the agent uses it
			660 container rule-A-048
				661 text A-048 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				662 button Copy a link to this rule
				663 heading Assessment artifacts that must stay in the record (ARTS), Value: 3
					664 text Assessment artifacts that must stay in the record (ARTS)
				665 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.
				666 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					667 text Source, evidence and how the agent uses it
			668 container rule-A-049
				669 text A-049 State Medicaid manual (DMAS) Primary text 2.1, 2.5
				670 button Copy a link to this rule
				671 heading Comprehensive ISP contents and ISP reviews (ARTS), Value: 3
					672 text Comprehensive ISP contents and ISP reviews (ARTS)
				673 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.
				674 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					675 text Source, evidence and how the agent uses it
			676 container rule-A-050
				677 text A-050 State Medicaid manual (DMAS) Primary text ALL ARTS
				678 button Copy a link to this rule
				679 heading Diagnosis codes must match across record, authorization and claim, Value: 3
					680 text Diagnosis codes must match across record, authorization and claim
				681 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.
				682 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					683 text Source, evidence and how the agent uses it
			684 container rule-A-051
				685 text A-051 State Medicaid manual (DMAS) Primary text ALL ARTS
				686 button Copy a link to this rule
				687 heading Drug testing: how results are meant to be used, Value: 3
					688 text Drug testing: how results are meant to be used
				689 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.
				690 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					691 text Source, evidence and how the agent uses it
			692 container rule-A-052
				693 text A-052 State Medicaid manual (DMAS) Primary text ALL ARTS
				694 button Copy a link to this rule
				695 heading Service authorization rules updated 2026 (Appendix D), Value: 3
					696 text Service authorization rules updated 2026 (Appendix D)
				697 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.
				698 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					699 text Source, evidence and how the agent uses it
			700 container rule-M-001
				701 text M-001 MCO contract / provider manual Primary text ALL
				702 button Copy a link to this rule
				703 heading Who the payers are (Virginia Medicaid), Value: 3
					704 text Who the payers are (Virginia Medicaid)
				705 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.
				706 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					707 text Source, evidence and how the agent uses it
			708 container rule-M-002
				709 text M-002 MCO contract / provider manual Primary text ALL
				710 button Copy a link to this rule
				711 heading MCO rules beyond the state manual, Value: 3
					712 text MCO rules beyond the state manual
				713 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.
				714 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					715 text Source, evidence and how the agent uses it
			716 container rule-M-003
				717 text M-003 MCO contract / provider manual Secondary: confirm Anthem HealthKeepers Plus only (example)
				718 button Copy a link to this rule
				719 heading Example of an MCO's provider dispute windows, Value: 3
					720 text Example of an MCO's provider dispute windows
				721 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.
				722 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					723 text Source, evidence and how the agent uses it
			724 container rule-C-001
				725 text C-001 Payer clinical criteria Primary text 2.1, 2.5
				726 button Copy a link to this rule
				727 heading ASAM 3rd vs 4th edition vocabulary, Value: 3
					728 text ASAM 3rd vs 4th edition vocabulary
				729 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.
				730 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					731 text Source, evidence and how the agent uses it
			732 container rule-C-002
				733 text C-002 Payer clinical criteria General: confirm Mental health; some SUD
				734 button Copy a link to this rule
				735 heading Other criteria sets payers may use, Value: 3
					736 text Other criteria sets payers may use
				737 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.
				738 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					739 text Source, evidence and how the agent uses it
			740 container rule-X-001
				741 text X-001 Accreditation / case law / guidance Primary text ALL (if accredited)
				742 button Copy a link to this rule
				743 heading Accreditation standards, Value: 3
					744 text Accreditation standards
				745 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).
				746 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					747 text Source, evidence and how the agent uses it
			748 container rule-X-002
				749 text X-002 Accreditation / case law / guidance Secondary: confirm Commercial plans (persuasive for Medicaid)
				750 button Copy a link to this rule
				751 heading Wit v. United Behavioral Health (commercial/ERISA), Value: 3
					752 text Wit v. United Behavioral Health (commercial/ERISA)
				753 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).
				754 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					755 text Source, evidence and how the agent uses it
			756 container rule-X-003
				757 text X-003 Accreditation / case law / guidance Secondary: confirm Commercial, fully insured
				758 button Copy a link to this rule
				759 heading Commercial external review (Virginia), Value: 3
					760 text Commercial external review (Virginia)
				761 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.
				762 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					763 text Source, evidence and how the agent uses it
			764 container rule-X-004
				765 text X-004 Accreditation / case law / guidance Secondary: confirm AI deployment
				766 button Copy a link to this rule
				767 heading Virginia AI statutes (watch), Value: 3
					768 text Virginia AI statutes (watch)
				769 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.
				770 button (collapsed) Source, evidence and how the agent uses it, Secondary Actions: Expand
					771 text Source, evidence and how the agent uses it

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