Outpatient Claim Reprocess
The January software update for the outpatient hospital Enhanced Ambulatory Patient Groups (EAPG) contained a system fix to correct the age calculation for vaccine procedure codes. New procedure codes were also released by CMS, effective January 1, 2018, and were updated in the MMIS. These system changes required outpatient hospital claims with dates of service on or after July 23, 2017 to be reprocessed. These claims will show on the remittance dated 03/23/18.
Inpatient Co-Payment Reduction
Hospitals should be made aware that, effective with dates of service on or after December 15, 2017, DMAS is reducing the cost sharing amounts for which facilities are liable for inpatient stays from $100 to $75. This change is required pursuant to federal changes in 42 CFR 447.52(b)(2) regarding maximum allowable cost sharing.
Outpatient Hospital Claims Reprocessing - November 2017
The July software update for the outpatient hospital Enhanced Ambulatory Patient Groups (EAPG) did not correctly apply the updated National Correct Coding Initiative (NCCI) edits. These edits were corrected in the MMIS software update for October. This system change required outpatient hospital claims with dates of service on or after July 1, 2017 and NCCI-related codes to be reprocessed. These claims will show on remittances dated 11/24/17.
DMAS would like to remind providers the importance of checking eligibility each time a member has services rendered. With the new CCC Plus roll out throughout the state, most members will be enrolled in one of six MCO plans. Checking eligibility will assure you bill the correct provider the first time you submit a claim, and your claims are paid promptly.
Please access the recorded session on the DMAS Website for information on verifying eligibility. https://dmastraining.adobeconnect.com/pk9bsgulxr50/?launcher=false&fcsContent=true&pbMode=normal
Attention All Providers of the Elderly or Disabled with Consumer Direction (EDCD) Waiver, and Tech Assisted (Tech) Waiver Services.
Virginia received approval from the Centers for Medicare and Medicaid Services (CMS) to combine the Elderly or Disabled with Consumer Direction (EDCD) Waiver with the Technology Assisted (Tech) Waiver, to be effective 7/1/2017. The new waiver is named the Commonwealth Coordinated Care Plus (CCC Plus) Waiver. Individuals served through the EDCD and Tech Waivers will automatically continue services through the CCC Plus Waiver. All service authorizations for the EDCD and Tech Waivers will continue; providers do not need to take any additional actions at this time. The effective date of the CCC Plus Waiver is July 1, 2017 and should not be confused with the implementation of the Commonwealth Coordinated Care Plus (CCC Plus) managed care program effective August 1, 2017. Please refer to the DMAS Provider Memo, dated 6/6/2017, Launch of Commonwealth Coordinated Care (CCC) Plus Waiver - Effective July 1, 2017 for additional details. This is available from DMAS at: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/MedicaidMemostoProviders
For more information contact the DMAS Helpline at 1-800-552-8627 or 804-786-6273.
Delayed Remittance Scheduled for June 30, 2017
The 2014 Appropriation Act requires that the remittance that normally would be paid on Friday, June 30, 2017 will instead be paid on Friday, July 7, 2017. This annual delay was originally communicated in our Medicaid Memo of May 14, 2010. All claims will be processed as usual based on the date they are received. Furthermore, providers will be able to verify claims status information via MediCall and ARS without disruption. Providers should plan accordingly and prepare for this delay in claims payment. DMAS will not issue advance pays associated with this delay.
To all Medicaid Providers: Provider Appeal Request form now available
There is now a form available on the DMAS website to assist providers in filing an appeal with the DMAS Appeals Division. The link to the page is http://www.dmas.virginia.gov/Content_pgs/appeal-home.aspx and the form can be accessed from there by clicking on "Click here to download a Provider Appeal Request Form." The form is in PDF format and has fillable fields. It can either be filled out online and then printed or downloaded and saved to your business computer. It is designed to save you time and money by assisting you in supplying all of the necessary information to identify your area of concern and the basic facts associated with that concern. Once you complete the form, you can simply print it and attach any supporting documentation you wish to, and send to the Appeals Division in the traditional manner.
DMAS would like to remind providers of the benefits available through Virginia's Plan First program services. The availability of family planning services allows individuals to achieve desired birth spacing and family size and contributes to improved health outcomes for infants, children and families. The following link will show you the covered services for the program:
If you have any questions please email PlanFirst@dmas.virginia.gov
Outpatient Hospital Claims and Ambulatory Surgical Centers
DMAS will reprocess outpatient hospital claims with line items that previously paid at zero/denied for Edit 0345. Claims with dates of service between January 1, 2014 and January 29, 2017 are affected. In addition, outpatient hospital and ambulatory surgery center claims with at least one new code effective January 1, 2017 will be reprocessed. Claims with new codes processed between January 1 and January 29, 2017 are affected. Both sets of claims will be reprocessed the week of March 6, 2017 with a remittance date of March 17, 2017.
Appeals Division Fax Number Change
Be advised that the DMAS Appeals Division fax number has changed. Effective September 1, 2017, the old Appeals Division fax number will no longer function, and faxes sent to the old number will not be received by the Appeals Division. The new fax number is (804) 452-5454. Please verify that the Appeals Division fax number currently programmed into your fax machine or computer and the fax number in any document sent to any client is the new Appeals Division fax number prior to the deadline.
Continuous Glucose Monitoring
Effective December 15, 2016, DMAS will CLARIFY THAT MEDICAID FEE-FOR-SERVICE COVERAGE of Continuous Glucose Monitoring (CGM) INCLUDES reimbursement for the sensor, transmitter, and receiver used with the invasive monitor. This equipment will be supplied by a Medicaid Durable Medical Equipment (DME) provider and billed as a DME item. Codes to be billed for the DME equipment are:
1) A9276 (CGM Sensor, invasive),
2)A9277 (CGM Transmitter; external) and
3) A9278 (CGM Receiver (monitor); external)
The CGM equipment requires service authorization. Providers will fax their requests on the Continuous Glucose Monitoring DME Request Form to the DMAS Medical Support Unit at 804-452-5450. The fax request form is available on the DMAS web portal in the Provider Services section. Refer to the DMAS Provider Memo, dated 11/2/2016, Clarification of Existing Medicaid Coverage of Continuous Glucose Monitoring (CGM) for members in Medicaid/FAMIS/FAMIS Fee-for-Service Programs-Effective for dates of service on or after December 15, 2016. This is available from DMAS at: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/MedicaidMemostoProviders.
As of October 1, 2016 DMAS has converted to version 33 of the 3M APR-DRG grouper. Recently, DMAS has identified claims, grouped by version 31, which did not group correctly. To correct the issue, DMAS will reprocess all inpatient hospital claims grouped incorrectly with discharge dates of service on or after October 1, 2015 through September 30, 2016 using version 33 of the grouper. This reprocess may result in additional payments or recoupments of overpayments for affected claims. Any reprocessed claims that do not pend will be reflected on the remittance advice dated 11/25/2016.
Change to the Service Authorization of Organ and Stem Cell Transplants and non-emergent, out-patient, out of state MRI, PET and CAT scans
Effective with request date of November 1, 2016, all physician requests of organ and bone marrow transplants and non-emergent, outpatient, out of state MRI, PET and CAT scans will be completed by the DMAS Medical Support Unit. Out of state is defined as any facility or provider not within the State of Virginia.
Providers who submit requests to KEPRO on or before October 31, 2016 will receive a final determination from KEPRO; providers are not to submit the same request to DMAS if the request was submitted to KEPRO.
This change only applies to members in the Medicaid and FAMIS Fee-for-Service programs and GAP. Members enrolled in Managed Care will follow the Prior Authorization process determined by the Managed Care plan. All requests as well as all pertinent medical information must be received at least 30 days prior to the date of the transplant procedure and/or diagnostic imaging. Providers will fax their requests to the DMAS Medicaid Support Unit, fax number 804-452-5450.
Hospitals will continue to submit to KEPRO their request for the in-patient hospitalization for the transplant. An approved physician authorization is required and must accompany the hospital request.
Please refer to the DMAS Provider Memo, dated 10/19/2016, Change to the Service Authorization of Organ and Stem Cell Transplants and non-emergent, out-patient, out of state MRI, PET and CAT scans - effective November 1, 2016 for additional details. This is available from DMAS at: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/MedicaidMemostoProviders.
Attention All Individual and Family Developmental Disabilities Support Waiver (DD Waiver) Case Managers:
Effective July 1, 2016, Keystone Peer Review Organization (KEPRO) will no longer process service authorization requests for DD Waiver services. All service authorization requests on or after July 1, 2016, must be submitted to the Department of Behavioral Health and Developmental Services (DBHDS). For more information contact the DBHDS Helpline at 804-663-7290 or access the DBHDS website: http://www.dbhds.virginia.gov/individuals-and-families/developmental-disabilities
Ambulatory Surgical Center and Outpatient Hospital Claim
This is to notify providers that Ambulatory Surgery Center (ASC) and Outpatient Hospital claims with dates of service on or after January 1, 2016 that were adjudicated prior to May 1, 2016 will be reprocessed the week of May 30, 2016 with a remittance date of June 10, 2016.
The 2016 Appropriation Act requires that the remittance that normally would be paid on Friday, June 24, 2016 will instead be paid on Friday, July 1, 2016. This annual delay was originally communicated in our Medicaid Memo of May 14, 2010. All claims will be processed as usual based on the date they are received. Furthermore, providers should plan accordingly and prepare for this delay in claims payment. DMAS will not issue advance pays associated with this delay.
Patient Pay Reprocess
For providers submitting Crossover claims incorrectly subjected to patient pay deductions, DMAS will void and reprocess the identified claims.
For providers submitting claims that were subject to patient pay deductions and the incorrect deduction of the patient pay resulted in claims processing with a smaller patient pay amount being deducted for NF, waiver or other LTC services, DMAS will void and reprocess the identified claims.
All corrected claims will show on the remittance dated April 22, 2016. Providers are responsible for reviewing the remittance advice associated with the patient pay reprocess.
For the List of top 10 commonly occurring X12 compliance issues, use the following URL:
Outpatient Emergency Room Claims Spanning 9/30/15-10/01/15 Dates of Service
DMAS is requiring providers billing only Outpatient emergency room and observation claims that span 9/30/15 - 10/01/15 to keep those charges on one claim and bill with the ICD-9 diagnosis code(s). These claims will suspend for review and be adjudicated by DMAS.
Effective with dates of service October 1, 2015, ICD-10 coding goes into effect. Our system is tested and ready to accept properly coded ICD-10 claims. In order to prevent a denial, claims with dates of service prior to the ICD-10 compliance date must be coded with ICD-9. Claims with dates of service on or after the compliance date must be coded with ICD-10. For those providers billing in-patient hospital charges, DMAS will be using the ICD-10 diagnoses for all UB claims with a discharge date on or after October 1, 2015. Claims must be coded with either ICD-9 or ICD-10 codes but not with both. For more information, please see the Medicaid Memo dated August 25, 2015. It can be found on the Virginia Medicaid Web Portal under the Provider Services tab. Please select Medicaid Memos and then select the Medicaid Memo dated August 25, 2015. DMAS will not be issuing advance payments due to lack of provider readiness.
NEW - Managed Long Term Services and Supports (MLTSS) Stakeholder Notice
Please read the following important announcement regarding Virginia's proposed managed long-term services and supports (MLTSS) initiatives. Consistent with Virginia General Assembly directives, over the next couple of years, the Department of Medical Assistance Services (DMAS) will transition the majority of the remaining Medicaid fee-for-service populations into coordinated and integrated managed care models. Additional information on DMAS proposed initiatives is available at the following link:
Online Enrollment Access
To enroll online you must be logged in as a registered provider. To register, please follow the instructions below.
How to register:
In the Login box click the Provider link. In the First Time User Registration box click the Web Registration link. Enter the requested information and click Continue.
After you are registered and logged into the web portal, click on the Provider Enrollment tab to proceed to the online enrollment applications.
WebEx Training Sessions
If you would like to view training sessions on various topics related to Medicaid, please go to dmas.webex.com and select Recorded Sessions on the left panel.