Residential Treatment Facility Rate Changes - Effective July 1, 2021
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The purpose of this bulletin is to inform Psychiatric Residential Treatment Facilities (PRTFs), Residential Levels of Care for the American Society of Addiction Medicine (ASAM) including Medically Monitored Intensive Inpatient Services (Adult), Medically Monitored High Intensity Inpatient Services (Adolescent) (ASAM Level 3.7), Clinically Managed High-Intensity Residential Services (Adult) and Clinically Managed Medium-Intensity Residential Services (Adolescent) (ASAM Level 3.5) and Clinically Managed Population-Specific High Intensity Residential Service (ASAM Level 3.3) facilities of rate changes mandated by the 2021 Appropriation ACT. All rate changes are effective July 1, 2021.
In accordance with Item 313.CC of the 2021 Appropriation ACT, DMAS will revise the per diem rates paid to Virginia-based PRTFs and Residential ASAM Level 3.3/3.5/3.7 facilities using the provider’s audited cost per day from the facility’s cost report for provider fiscal years ending in state fiscal year 2018. New Virginia-based residential treatment facilities must submit proforma cost report data, which will be used to set the initial per diem rate based on an audited cost report for a 12-month period within the first two years of operation.
If necessary to enroll out-of-state providers for network adequacy, the department shall negotiate rates. If there is sufficient utilization, the department may require out-of-state providers to submit a cost report to establish a per diem rate.
In-state and out-of-state provider per diem rates shall be subject to a $423.32 rate ceiling based on the statewide weighted average cost per day based on data from fiscal year 2018 cost reports.
Virginia-based Residential Treatment Facilities that do not submit cost reports shall be paid at 75 percent of the established rate ceiling.
Magellan of Virginia serves as the Behavioral Health Services Administrator or "BHSA" and is responsible for the management and administration of the fee for service (FFS) behavioral health benefit programs under contract with DMAS, including those for PRTFs. For more information about Magellan of Virginia, please consult Magellan’s National Provider Handbook, the Magellan Virginia Provider Handbook, contact Magellan of Virginia at (800) 424-4536 or VAProviderQuestions@MagellanHealth.com, or visit http://www.magellanofvirginia.com.
For questions regarding residential treatment facility rates and to get instructions on how to submit cost reports, please contact Taryn Gulkewicz at (804) 786-0037 or email Taryn.Gulkewicz@dmas.virginia.gov.
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PROVIDER CONTACT INFORMATION & RESOURCES |
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Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. |
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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 |
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KEPRO Service authorization information for fee-for-service members.
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Provider Appeals DMAS is launching an appeal portal in late May 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. |
https://www.dmas.virginia.gov/#/appealsresources
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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. |
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Medallion 4.0 |
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CCC Plus |
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PACE |
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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 For credentialing and behavioral health service information, visit: www.magellanofvirginia.com, email: VAProviderQuestions@MagellanHealth.com,or Call: 1-800-424-4046 |
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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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Aetna Better Health of Virginia |
www.aetnabetterhealth.com/Virginia 1-800-279-1878 |
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Anthem HealthKeepers Plus |
1-800-901-0020 |
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Magellan Complete Care of Virginia |
1-800-424-4518 (TTY 711) or 1-800-643-2273 |
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Optima Family Care |
1-800-881-2166 www.optimahealth.com/medicaid |
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United Healthcare |
and www.myuhc.com/communityplan 1-844-752-9434, TTY 711 |
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Virginia Premier |
1-800-727-7536 (TTY: 711), www.virginiapremier.com |