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Patient Pay Underpayments - UPDATE

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Effective Date:

All Providers and Managed Care Organizations Participating with the Medicaid/FAMIS Programs
Cheryl J. Roberts, Director Department of Medical Assistance Services (DMAS)

This bulletin is an update to the July 26, 2023 bulletin notifying long term services and supports providers that DMAS had issued a broadcast notice to local departments of social services that staff should immediately stop calculating patient pay underpayments for nursing facility residents.

The original guidance obtained from CMS contained information that patient pay underpayments should no longer be calculated. Medicaid members are not responsible for an increased patient pay until they have been given advanced notice concerning the change.

DMAS staff have manually corrected any underpayments that have been calculated since April 1, 2023 since those underpayments may have been included in the patient pay calculation. To correct these cases, DMAS removed the applied underpayment (reducing the patient pay) and used current income to determine the ongoing patient pay after the member was given 10 days advance notice. 

 This correction will result in some members being issued a revised (lower) patient pay for a past month. DMAS will correct the Capitation payment paid to the managed care organizations (MCOs) by voiding the original payment and paying the correct amount. MCOs should review their contracts regarding making the correct payment to service providers. Providers should review the Monthly Patient Pay Report and return any patient pay overpayments to the member. 


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.

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.

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