Current through Register Vol.. 38, No. 17, April 11, 2022
A. Quality management review shall be
performed by DMAS or its designee. Utilization review of rendered services
shall be conducted by DMAS or its designee.
B. DMAS staff shall conduct utilization
review of individual-specific provider documentation, which shall be forwarded
by providers upon DMAS or DBHDS request.
Utilization review requirements specific
to services in the developmental disability waivers shall be as follows:
1. To apply to be reimbursed as a Medicaid
provider, the required DBHDS license shall be either a conditional or full
(either annual or triennial) license.
2. Providers with provisional licenses issued
by DBHDS shall not be reimbursed as Medicaid providers beginning 60 days from
the issuance of the provisional license. Providers shall not request or receive
authorizations or reauthorizations for services for new or currently supported
individuals upon the issuance of the provisional license.
3. Reimbursement shall not be permitted to
providers that fail to enter into a provider agreement with DMAS for a service
prior to rendering that service or fail to maintain a current Medicaid Provider