# 12 Va. Admin. Code § 30-120-400: 12VAC30-120-400. Quality control and utilization review

> Virginia · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_400

## Section

- **Citation:** 12 Va. Admin. Code § 30-120-400
- **Heading:** 12VAC30-120-400. Quality control and utilization review
- **Jurisdiction:** Virginia
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Virginia Administrative Code / Title 12 Health / Agency 30 Department of Medical Assistance Services / Chapter 120 / 12VAC30-120-400

## Text

A. DMAS shall rigorously monitor the quality of care provided by the MCOs. DMAS and the MCOs shall comply with (i) the contract; (ii) 42 CFR 438 Subpart E, entitled Quality Measurement and Improvement: External Quality Review; and (iii) the MCO standards identified in 42 CFR 438 Subpart D, entitled MCO, PIHP, and PAHP Standards. DMAS shall monitor the MCOs to determine their compliance with the contract, 42 CFR Subpart A, and all other relevant sections of 42 CFR Part 438 (Managed Care) as follows:
1. If the MCO fails substantially to provide the medically necessary items and services required under law or under the contract to be provided to an enrolled recipient and the failure has adversely affected or has substantial likelihood of adversely affecting the individual.
2. If the MCO engages in any practice that discriminates against individuals on the basis of their health status or requirements for health care services, including expulsion or refusal to reenroll an individual, or any practice that could reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by § 1903(m) of the Social Security Act (42 USC § 1396(m)) by eligible individuals whose medical conditions or histories indicate a need for substantial future medical services.
3. If the MCO misrepresents or falsifies information that it furnishes, under § 1903(m) of the Social Security Act (42 USC § 1396b(m)) to CMS, DMAS, an individual, or any other entity.
4. If the MCO fails to comply with the requirements of 42 CFR 417.479(d) through 42 CFR 417.479(g) relating to physician incentive plans or fails to submit to DMAS its physician incentive plans as required or requested in 42 CFR 434.70.
5. If the MCO imposes on members premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program.
B. DMAS shall ensure that data on performance and patient results are collected.
C. DMAS shall ensure that quality outcomes information is provided to MCOs
e plans or fails to submit to DMAS its physician incentive plans as required or requested in 42 CFR 434.70.
5. If the MCO imposes on members premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program.
B. DMAS shall ensure that data on performance and patient results are collected.
C. DMAS shall ensure that quality outcomes information is provided to MCOs. DMAS shall ensure that changes that are determined to be needed as a result of quality control or utilization review are made.

## Nearby sections

- [12 Va. Admin. Code § 30-120-360 12VAC30-120-360. Definitions](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_360.md)
- [12 Va. Admin. Code § 30-120-370 12VAC30-120-370. Medallion mandatory managed care members](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_370.md)
- [12 Va. Admin. Code § 30-120-380 12VAC30-120-380. Medallion MCO responsibilities](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_380.md)
- [12 Va. Admin. Code § 30-120-390 12VAC30-120-390. Payment rate for MCOs](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_390.md)
- [12 Va. Admin. Code § 30-120-395 12VAC30-120-395. Preauthorized, emergency, and post-stabilization services and payment rate for care provided by out-of-network providers](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_395.md)
- [12 Va. Admin. Code § 30-120-400 12VAC30-120-400. Quality control and utilization review](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_400.md)
- [12 Va. Admin. Code § 30-120-410 12VAC30-120-410. Sanctions](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_410.md)
- [12 Va. Admin. Code § 30-120-420 12VAC30-120-420. Member grievances and appeals](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_420.md)
- [12 Va. Admin. Code § 30-120-430 12VAC30-120-430. Provider grievances, reconsiderations, and appeals](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_430.md)
- [12 Va. Admin. Code § 30-120-600 12VAC30-120-600. Definitions](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_600.md)
- [12 Va. Admin. Code § 30-120-610 12VAC30-120-610. CCC Plus mandatory managed care members enrollment process](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_610.md)
- [12 Va. Admin. Code § 30-120-615 12VAC30-120-615. CCC Plus providers; Medicaid enrollment process](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_615.md)
- [12 Va. Admin. Code § 30-120-620 12VAC30-120-620. MCO responsibilities; sanctions](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_620.md)
- [12 Va. Admin. Code § 30-120-625 12VAC30-120-625. Continuity of care](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_625.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_12_30_120_400. Check the current official text before relying on it. Not legal advice.