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The purpose of this bulletin is to provide information for successful adjudication and payment of claims for undocumented individuals. Emergency Medical Certification is available for undocumented individuals who have a life threatening emergency event.

Services Provided Prior to July 1, 2022

Undocumented individuals are not eligible for ongoing Medicaid coverage for emergency admissions and dates of service prior to July 1, 2022.  Medicaid eligibility for undocumented individuals who were admitted prior to July 1, 2022, will only be for the approved outpatient or inpatient time periods that service was provided. Providers must submit emergency medical Emergency Medical Certification admissions, which began prior to July 1, 2022, to DMAS using the prior paper or electronic e-mailbox process. All requests for review must contain:

• Submission of the completed Emergency Medical Certification form
• Medical record to accompany the specific time period requested

Services Provided On and After July 1, 2022

Effective July 1, 2022, DMAS’s Medicaid Enterprise System (MES) is assigning the following aid categories applicable to the undocumented population.  Covered services have not changed. These aid categories are eligible for emergency services only.

1. Aid Category 112 Expansion population/Modified adjusted gross income (MAGI) Adults
2. Aid Category 113 Non-MAGI/ABD/Children

Effective July 1, 2022, the new Aid Categories 112 and 113 are applicable for admissions that began on or after July 1, 2022 for services rendered on or after July 1, 2022.

For services provided on or after July 1, 2022, DMAS no longer requires review of medical records and Emergency Medical Certification forms.  Providers must submit claims for individuals enrolled with Aid Categories 112 and 113 directly to the DMAS fiscal agent, whose address is below.

Inpatient Hospital Providers

Hospital claims for undocumented individuals must include an attachment with the case discharge summary. The discharge summary will identify the admission and discharge date to the facility and a clinical summary of the hospital stay.

Emergency Department Providers

For undocumented individuals receiving inpatient or outpatient services through the Emergency Department without a hospital admission, providers must include the following information in the attachment they submit with their claim: the date and time of entry and discharge, as well as the clinical summary of events during the Emergency Department stay.

Professional Providers

Professional claim adjudication is contingent upon the receipt, adjudication and payment of the hospital or emergency department claims.

Need for Service Authorization (SA)

When a claim denies for service authorization, DMAS staff will enter the SA into the Medicaid Management Information System (MMIS). Not all emergency medical certification claims will require SA. When DMAS enters the SA in MMIS, the provider will receive an MMIS-generated letter with the SA number. The provider must resubmit the claim and include the SA number for claim adjudication.

All providers

Providers can find a list of examples of covered services in Chapter IV of the Physician/Practitioner Manual and the Hospital Manual. The services must meet emergency treatment criteria in order to qualify for coverage. Billing instructions are in Chapter V of the Hospital and the Physician/Practitioner Provider Manuals.

For hospitals submitting paper claims, include the attachments indicated above and send to:  

Department of Medical Assistance Services

P.O. Box 27443

Richmond, Virginia  23261

For physicians and practitioners submitting paper claims, include the attachments indicated above and send to:

Department of Medical Assistance Services

P.O. Box 27444

Richmond, Virginia 23261

Providers must submit electronic claims with an ACN (attachment control number) indicating that a paper attachment is forthcoming. Billing instructions are in Chapter V of the Hospital Provider Manual.

Use of the DMAS-3 Form

Electronic Data Interchange billers should only use the DMAS-3 form to submit a non-electronic attachment to an electronic claim.

Providers must identify the ACN on the electronic claim they submit. If the ACN on the claim does not match the ACN in the attachment, DMAS will deny the claim.

When a claim is pended for the attachment, providers have 21 calendar days to submit the requested attachment. Pends without provider response will automatically deny after 21 calendar days.

Instructions for the completion of the DMAS-3 is located in the Exhibits section of the Hospital Manual and the Physician/Practitioner’s Manual.