Hospital & Ambulatory Surgical Centers (ASCs) Solventum Fee-for-Service Grouper Updates– Effective July 1, 2024
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The purpose of this bulletin is to notify hospitals and Ambulatory Surgical Centers (ASCs) about the delay in updating the Solventum, formerly known as 3M, All Patient Refined Diagnosis-Related Group (APR-DRG) and Enhanced Ambulatory Patient Group (EAPG) versions and weights for state fiscal year 2025 (SFY25). This bulletin serves as an update to the July 8, 2024, bulletin titled “Inpatient and Outpatient Hospital Rates Effective July 1, 2024”.
Implementation of the new grouper version and weights has been delayed. Any fee-for-service claims submitted after the close of business September 9, 2024, will be processed at the rates published in the July 8, 2024, bulletin "Inpatient and Outpatient Hospital Rates Effective July 1, 2024".
Claims paid between July 1, 2024, and prior to the implementation of the updated grouper and weights will be automatically reprocessed on September 13, 2024. This action will be reflected in the remittance dated September 20, 2024. The Virginia-specific Diagnosis- Related Group (DRG) weights, as well as other inpatient reimbursement parameters, are available on the DMAS web site at https://www.dmas.virginia.gov/for-providers/rates-and-rate-setting/hospital-rates/.
If you have any questions pertaining to the rates processed for MCO claims, please contact the MCOs.
Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. | |
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. | |
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 | |
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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 |
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Anthem HealthKeepers Plus | 1-800-901-0020
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Molina Complete Care
| 1-800-424-4524 https://www.molinahealthcare.com/providers/va/medicaid/home.aspx
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Sentara Community Plan | 1-800-881-2166 https://www.sentarahealthplans.com/providers
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United Healthcare | 1-844-284-0149
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