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The purpose of this bulletin is to provide updated claims processing details for the select HCBS services that received a rate increase effective July 1, 2021 through June 30, 2022.  For the purposes of this rate increase HCBS includes a specific set of waiver, behavioral health, home health, Early, Periodic, Screening, Diagnosis and Treatment (EPSDT), and other services in compliance with Centers for Medicare & Medicaid Services (CMS) guidance.  In accordance with Item 313.SSSS of the 2021 Acts of Assembly the 12.5 percent rate increase for agency- and consumer-directed personal care, respite and companion services in the HCBS waivers and EPSDT program becomes permanent effective January 1, 2022 while the temporary increases for the other service areas will continue until June 30, 2022.  For details on the specific services and billing codes subject to the rate increase, refer to the October 6, 2021 Medicaid Bulletin (available at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/MedicaidMemostoProviders). 

DMAS implemented the changes to address prospective claims on October 8, 2021 for Fee for Service (FFS) providers while Managed Care Organizations and the Behavioral Health Service Administrator (Magellan of Virginia) implemented these changes on a prospective basis on October 22, 2021.  However, since that time DMAS has not been able to secure approval from CMS to allow a mass adjustment of claims to provide the additional reimbursement to providers and there have been some inconsistent allowances from the MCO’s when providers have requested to initiate claims adjustments for the period of July 1, 2021through October 22, 2021 which has led to some confusion about how to access the additional funds available to this provider group.

This memo serves to provide current claims processing guidance for FFS, BHSA and MCO providers while The Department continues working to secure authority from CMS on the methods to re-process claims for the impacted providers in the MCO and BHSA delivery systems.  Once the CMS authority is secured, all DMAS contracted MCO’s and the BHSA will implement this automated mass claims re-processing option for their network providers regardless of any timely filing rules because the claims in need of adjustment have already been adjudicated.  Please note that any new, adjusted or resubmitted claims, not previously submitted for adjudication must abide by timely filing rules as defined in chapter 5 of DMAS program manuals or in the MCO or BHSA provider contracts.  It is important to note that any provider who voids and submits adjusted claims for the higher rate amount should confirm that the voided claim was adjudicated successfully before submitting an adjusted claim to avoid processing errors due to the duplicated claims.

Retrospective Claims

The Department of Medical Assistance Services (DMAS) continues work with our partners at CMS to obtain authorization to adjust previously billed and adjudicated claims with dates of services between July 1, 2021 and October 22, 2021. DMAS is also working with the MCOs and the BHSA (Magellan of Virginia), to operationalize plans for this process to be prepared once authorization is granted.  The State is seeking options to alleviate provider burden in this process and subsequent information will be made available in a memo once CMS provides guidance to the State.

DMAS and the MCOs are working to develop a process and timeline to adjust payments for Consumer-Directed (CD) services delivered and paid between July 1, 2021 and October 7, 2021.  Employers of Record (EORs) and attendants will be notified of the timeline when it is determined.    

Please note that any FFS claims that were adjudicated by the DMAS Medicaid Management and Information System (MMIS) will not be reprocessed due to MMIS system limitations as the new Medicaid Enterprise System (MES) is being implemented.  FFS providers must submit adjusted claims to receive any retrospective rate increases.  DMAS will continue to explore options to resolve this process through MMIS and MES but as of this writing date unfortunately there is no other option.

Temporary Retrospective Claims Processing Guidelines (while awaiting CMS Approval)

MCO and BHSA Provider Claims Processing Resources:

Aetna

https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/virginia/provider/pdf/provider_manual_2021.pdf

Anthem

https://providernews.anthem.com/virginia/article/essential-information-you-need-to-submit-edi-corrected-claims-3

Molina

https://www.molinahealthcare.com/providers/va/medicaid/resources/provider-materials.aspx

Optima

https://www.optimahealth.com/documents/provider-orientation/003-job-aid-view-claim-status-submit-reconsideration-online.pdf

United Healthcare

UHCprovider.com Home | UHCprovider.com

Virginia Premier:   

https://www.virginiapremier.com/wp-content/uploads/ProviderCorrectedClaimUpdate.pdf

BHSA-Magellan of Virginia

www.MagellanHealth.com/Provider

Temporary HCBS rate update

New rates are posted on the DMAS website.

• Waiver rates are provided at https://www.dmas.virginia.gov/for-providers/long-term-care/waivers/ under “CCC Plus Waiver Rates” and “Developmental Disabilities Waiver Rates”.
• ARTS rates are provided at https://www.dmas.virginia.gov/for-providers/addiction-and-recovery-treatment-services/information-and-provider-map/ under the “ARTS Reimbursement Structure” link.
• Mental Health service rates are provided at: https://www.dmas.virginia.gov/for-providers/behavioral-health/
• Home Health rates are provided at https://www.dmas.virginia.gov/for-providers/rate-setting/  under “Home Health”.
• Service rates that are not published under a specific program or a waiver rate sheets can be checked by using our code search webpage at https://www.dmas.virginia.gov/for-providers/general-information/procedure-fee-files-cpt-codes/. Procedure codes that start with a number can use our “Search CPT codes” function. Procedure codes that start with a letter need to be searched manually in our “HCPC Codes” file.

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