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The purpose of this bulletin is to notify providers that effective July 1, 2025, the rates for Resource Based Relative Value Scale (RBRVS) for Physician payments are updated in accordance with the CMS Physician Fee Schedule (CMS-1807-F) and Chapter 12 of the Virginia Administrative Code section 12VAC30-80-190. 

SFY 2026 Rate Notification

This bulletin serves as the official notification that rates for SFY 2026 are posted on the DMAS website. Procedure code rates may be found on the DMAS website at https://dmas.virginia.gov/for-providers/rates-and-rate-setting/ in the Procedure Fee Files & CPT Codes section.

If you have any questions regarding rates, please call the provider helpline at 800-552-8627.

DMAS and its Managed Care Organization (MCO) partners are diligently working on the implementation of new provider rates set forth in the 2025 Appropriations Act. As these rates are legislatively mandated and will be incorporated into the FY2026 Cardinal Care Managed Care (CCMC) capitation rates, MCOs are required to increase their reimbursement to providers at the same percentage increase as reflected in the revised FFS rates. The MCOs may need 30-60 days from 6/15/2025 to finish updating their systems with the new FY2026 rates. The MCOs will automatically reprocess any claims that paid using old rates within approximately 30 days after they finish updating their systems to the new rates.

Currently, providers have the option to bill MCOs immediately under old rates or delay billing until FY2026 rates are updated by the MCOs.

Appeals Information

If you believe an error was made for payment rates or totals, you can file an appeal.  The appeal must be filed with the DMAS Appeals Division through one of the following methods: 

• Through the Appeals Information Management System at https://www.dmas.virginia.gov/appeals/. From there you can fill out an informal appeal request, submit documentation, and follow the process of your appeal. 

• Through mail, email, or fax.  You can download a Medicaid Provider Appeal Request form at https://www.dmas.virginia.gov/appeals/. You can use that form or a letter to file the informal appeal.  The appeal request must identify the issues being appealed. The request can be submitted by:  

  • Mail or delivery to: Appeals Division, Department of Medical Assistance Services, 600 E. Broad Street, Richmond, VA 23219; 

  • Email to appeals@dmas.virginia.gov; or 

  • Fax to (804) 452-5454. 

The appeal must be received by the DMAS Appeals Division within 30 days of the payment rate or total being published by DMAS. The notice of appeal is considered filed when it is date stamped by the DMAS Appeals Division.  The normal business hours of DMAS are from 8:00 a.m. through 5:00 p.m. on dates when DMAS is open for business. Documents received after 5:00 p.m. on the deadline date shall be untimely.

To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions.  Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.