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Annual Service Plan Contractor for Fee-For Service Individuals on the CCC Plus Waiver with PDN Effective 3/11/2025

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Bulletin
Effective Date:

To:
All Fee For Service Commonwealth Coordinated Care (CCC) Plus Waiver Private Duty Nursing (PDN) Providers
From:
Cheryl J. Roberts, Director Department of Medical Assistance Services (DMAS)

The purpose of this bulletin is to inform fee for service (FFS) private duty nursing (PDN) providers who perform services under the CCC Plus Waiver that  the process for the member’s annual level of care reviews and service plan development will change. Providers will no longer perform annual level of care (LOC) reviews for members. Effective November 18, 2024, Acentra Health will perform the annual level of care assessments. 

The Centers for Medicare and Medicaid Services (CMS) requires that an individual receiving Home and Community-Based Services (HCBS) through a 1915(c) waiver have an annual person-centered service plan as well as an annual review of the individual’s level of care.  These requirements are to ensure that the individual still meets the necessary criteria for the waiver and that the service plan addresses the individual’s person-centered needs, preferences, and goals and identifies all services and providers the individual is using to meet those identified needs.  Previously, for FFS individuals who receive PDN through the CCC Plus Waiver, DMAS required FFS providers  conduct the annual level of care review (LOCERI) and  use the provider-developed plan of care, which identifies the tasks performed in a service, as the individual’s annual service plan.

As part of the CCC Plus Waiver’s five-year renewal, CMS determined that the development of the annual service plan by the provider constitutes a conflict of interest as DMAS must ensure that members have a choice when picking services and providers.  CMS has identified this conflict of interest for the FFS population only. This conflict of interest does not apply to members receiving PDN through the CCC Plus Waiver under managed care because the care manager develops the overall service plan. DMAS is now required to change the service plan development process for the FFS members receiving PDN through the CCC Plus Waiver. 

Effective November 18, 2024, Acentra Health (formerly KePRO), the FFS service authorization contractor,  will conduct annual level of care reviews and develop the annual service plan, using a modified version of the DMAS-108 (PDN – Adults) and DMAS-109 (PDN- Children), for FFS members enrolled in the CCC PlusWaiver who receive PDN.  Providers will no longer be responsible for conducting the LOCERI reviews due November 18, 2024 or later.

Acentra Health will contact members by phone to schedule the face-to-face visit to conduct the level of care review and develop the person-centered service approximately sixty days prior to the LOCERI due date.  If the Acentra Health care manager is not able to reach the member, they may contact the waiver provider for assistance in scheduling the visit. 

What Providers Can Do to Assist

Acentra Health will notify current FFS members receiving PDN through the CCC Plus Waiver of this change.  Providers should inform affected members that this annual visit is required for all FFS members who receive PDN through the CCC Plus Waiver and encourage them to respond to Acentra Health’s request to schedule a face-to-face visit in a timely fashion. 

Acentra Health has started the annual level of care reviews for these members and will continue these visits ongoing.  

To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions. Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.

PROVIDER CONTACT INFORMATION & RESOURCES

Virginia Medicaid Web Portal Automated Response System (ARS)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

https://vamedicaid.dmas.virginia.gov/

Medicall (Audio Response System)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

1-800-884-9730 or 1-800-772-9996

Provider Appeals

DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal.

https://www.dmas.virginia.gov/appeals/

Managed Care Programs

Cardinal Care Managed Care and Program of All-Inclusive Care for the Elderly (PACE).  In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider.  The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals.

Cardinal Care Managed Care

https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-…

PACE

Program of All-inclusive Care (virginia.gov)

Provider Enrollment

In-State: 804-270-5105

Out of State Toll Free: 888-829-5373

Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com

Provider HELPLINE

Monday–Friday 8:00 a.m.-5:00 p.m.  For provider use only, have Medicaid Provider ID Number available.

1-804-786-6273

1-800-552-8627

Aetna Better Health of Virginia

https://www.aetnabetterhealth.com/virginia/providers/index.html

1-800-279-1878

Anthem HealthKeepers Plus

http://www.anthem.com/

1-800-901-0020

Molina Complete Care

1-800-424-4524

https://www.molinahealthcare.com/providers/va/medicaid/home.aspx

Sentara Community Plan

1-800-881-2166 https://www.sentarahealthplans.com/providers

United Healthcare

www.uhcprovider.com/

1-844-284-0149

Dental Provider

DentaQuest

1-888-912-3456

Fee-for-Service (POS)

Prime Therapeutics

https://www.virginiamedicaidpharmacyservices.com/

1-800-932-6648

Acentra Health

Behavioral Health and Medical Service Authorizations

https://vamedicaid.dmas.virginia.gov/sa

1-804-622-8900

To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions.  Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.

PROVIDER CONTACT INFORMATION & RESOURCES

Virginia Medicaid Web Portal Automated Response System (ARS)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

https://vamedicaid.dmas.virginia.gov/

Medicall (Audio Response System)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

1-800-884-9730 or 1-800-772-9996

Provider Appeals

DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal.

https://www.dmas.virginia.gov/appeals/

Managed Care Programs

Cardinal Care Managed Care and Program of All-Inclusive Care for the Elderly (PACE).   In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider.  The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals.

Cardinal Care Managed Care

https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-…

PACE

Program of All-inclusive Care (virginia.gov)

Provider Enrollment

In-State: 804-270-5105

Out of State Toll Free: 888-829-5373

Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com

Provider HELPLINE

Monday–Friday 8:00 a.m.-5:00 p.m.  For provider use only, have Medicaid Provider ID Number available.

1-804-786-6273

1-800-552-8627

Aetna Better Health of Virginia 

https://www.aetnabetterhealth.com/virginia/providers/index.html

 1-800-279-1878

 

Anthem HealthKeepers Plus 

http://www.anthem.com/

1-800-901-0020

 

Molina Complete Care

 

1-800-424-4524 

https://www.molinahealthcare.com/providers/va/medicaid/home.aspx

 

Sentara Community Plan

1-800-881-2166 https://www.sentarahealthplans.com/providers

 

United Healthcare 

www.uhcprovider.com/

1-844-284-0149

 

Dental Provider

DentaQuest

1-888-912-3456 

Fee-for-Service (POS)

Prime Therapeutics 

 

https://www.virginiamedicaidpharmacyservices.com/

1-800-932-6648

Acentra Health

Behavioral Health and Medical Service Authorizations

https://vamedicaid.dmas.virginia.gov/sa

1-804-622-8900