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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-33

Effective Date: 07/01/05

33 Approval Date: _____________/06 B. Are furnished by an institution that is licensed or formally approved by the Virginia Department of Health and except in the case of medical supervision of nurse-midwife services, meets the requirements for participation in Medicare. C. Emergency hospital services provided without limitation. D. Coverage of outpatient observation beds. The following limits and requirements shall apply to DMAS coverage of outpatient observation beds. These services must be billed as outpatient care and may be provided for up to 23 hours. A patient stay of 24 hours or more shall require inpatient precertification and admission.

6.2.3.A ⌧ Physician services (Section 2110(a)(3))

A. Physician’s services whether furnished in the office, the patient’s home, a hospital, a skilled nursing facility or elsewhere. Elective surgery as defined by the Program is surgery that is not medically necessary to restore or materially improve a body function. Elective and cosmetic surgical procedures are not covered unless performed for physiological reasons and require prior approval by DMAS. B. Routine physicals and immunizations are not covered except when the services are provided under the EPSDT Program and when a well child examination is performed in a private physician’s office for a foster child of the local social services department on specific referral from those departments. B. Psychiatric services are limited to an initial availability of 26 sessions without prior authorization during the first year of treatment. An additional extension of up to 47 sessions during the first treatment year must be prior authorized by DMAS. The availability is further restricted to no more than 26 sessions each succeeding year when approved by DMAS. Psychiatric services are further restricted to no more than three sessions in any given seven-day period. Consistent with the Omnibus Budget Reconciliation Act of 1989 §6403, medically necessary psychiatric services shall be covered when prior authorized by DMAS for individuals younger than 19 year of age when the need for such services has been identified through an EPSDT screen. D. Physician visits to inpatient hospital patients are limited to medically necessary days of inpatient hospitalization. E. Psychological testing and psychotherapy by clinical psychologists licensed by the State Board of Medicine.