Minimum Data Set (MDS) changes effective October 1, 2023
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The purpose of this bulletin is to address MDS Assessment changes. Effective October 1, 2023 Centers for Medicare and Medicaid Services (CMS) will no longer have Section G in the MDS. Providers must use the Optional State Assessment (OSA) to generate a Resource Utilization Group (RUG) billing code for DMAS claims payment.
Completing the OSA
The OSA must be completed in accordance with Omnibus Budget Reconciliation Act of 1987 (OBRA) assessment scheduling. The purpose of the OSA is to generate a Virginia Medicaid RUG-IV billing code for DMAS claims payment. Providers are not required to assess members earlier than their normal scheduled MDS assessment due to the addition of the OSA effective October 1, 2023. Please see the DMAS Nursing Facility Provider manual and CMS MDS Manuals for more specific guidance.
Software Requirements
Software setting requirements for RUG-IV Grouper 48 will remain the same. However, the transition to the OSA will require providers to work with their software vendor to ensure current RUG-IV Grouper 48 settings are incorporated into the OSA correctly. Any software updates will need to be completed prior to completing an OSA. Please work with the MDS coordinator at VDH for technical assistance.
Resources:
CMS OSA and Resident Assessment Instrument (RAI) manual downloads
Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS
Nursing Facility Manual Chapter 5 and Chapter 11 (Appendix F)
Nursing Facilities | MES (virginia.gov)
MDS Coordinator
DMAS Helpline
1-800-552-8627
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 |
Acentra Health Service authorization information for fee-for-service members.
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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 Medallion 4.0, Commonwealth Coordinated Care Plus (CCC Plus), 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. | |
Medallion 4.0 | |
CCC Plus | |
PACE | |
Magellan Behavioral Health Behavioral Health Services Administrator, check eligibility, claim status, service limits, and service authorizations for fee-for-service members. | www.MagellanHealth.com/Provider www.magellanofvirginia.com, email: VAProviderQuestions@MagellanHealth.com,or Call: 1-800-424-4046 |
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 | www.aetnabetterhealth.com/Virginia 1-855-270-2365 1-866-386-7882 (CCC+) |
Anthem HealthKeepers Plus | 1-833-207-3120 1-833-235-2027 (CCC+) |
Molina Complete Care
| 1-800-424-4524 (CCC+) 1-800-424-4518 (M4) |
Optima Family Care | 1-800-643-2273 1-844-374-9159 (CCC+) |
United Healthcare | 1-844-284-0149 1-855-873-3493 (CCC+) |
Dental Provider DentaQuest | 1-888-912-3456 |