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The purpose of this Medicaid Bulletin is to provide clarification on requirements for Medicaid providers submitting appeals on behalf of Medicaid Members when a service or medication has not yet been provided. If the service or medication has been provided, the provider can seek a provider appeal to contest authorization or payment denials by following the provider appeal process.

In instances where the service or medication has not been provided and the Managed Care Organization’s internal appeal process has been exhausted (if applicable), providers requesting appeals on behalf of Medicaid members are required to submit written proof of authority to act on behalf of the member in accordance with 12 VAC 30-110-60. However, the DMAS Appeals Division frequently receives appeals from providers for medication denials (and other services) on behalf of Medicaid members without proper authorization. The Appeals Division cannot process these appeals without the proper written authorization.

Pursuant to 12 VAC 30-110-60, an appeal may be submitted by an authorized representative who must be designated in a written statement that is signed by the Medicaid member or by a family member or other person acting on behalf of a Medicaid member who is physically or mentally unable to sign a written statement. Proof of designation as authorized representative must accompany the appeal request in order for the request to be processed and scheduled for a hearing. This includes expedited appeal requests. The authorized representative form provided on the DMAS website (https://www.dmas.virginia.gov/appeals/)  is preferred, but not required. Failure to submit the required authorization with the appeal request will cause delays to the appeal.  An appeal will be dismissed if the authorization is not submitted in the timeframe required by DMAS. 

Appeal requests, including authorization letters, may be submitted and tracked online in the Appeals Information Management System ("AIMS"). Visit here to learn more.

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