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April 13, 2022, 11:54 EDT

Chapter : Hospital Reimbursement and Appeals of Reimbursement Rates

Hospital Reimbursement and Appeals of Reimbursement Rates

The Department of Medical Assistance Services (DMAS) sets rates for payments to hospitals under the Medicaid program pursuant to state and federal statutes and regulations. These regulations are subject to change and, for that reason, it is impracticable to reproduce them in this manual. The regulations may be obtained at any law library or any library that has the Virginia Administrative Code. The regulations may also be obtained at two locations on the Internet: at the website for DMAS, and at the website for the Virginia Code Commission.

DMAS Website

DMAS regulations affecting hospital reimbursement are available to the public, free of charge, at the following location at the DMAS website:

http://www.cns.state.va.us/dmas/

From this location, go to the section concerning laws and regulations. The hospital reimbursement regulations appear in that section.

Virginia Code Commission Website

The Virginia Administrative Code, including all of DMAS' permanent regulations, is available to the public, free of charge, at the following location at the Virginia Code Commission's website:

http://legis.state.va.us/codecomm/codhome.htm

Federal Regulations

The Code of Federal Regulations (CFR) is available to the public, free of charge, at the Government Printing Office (GPO) website. Medicaid regulations appear in Title 42 of the CFR. The URL for the GPO website is:

http://www.access.gpo.gov/nara/cfr/

Claims Adjudication

The Department of Medical Assistance Services (DMAS) is required to adjudicate all claims within 12 months of receipt, except in the following circumstances:

  • The claim is a retroactive adjustment paid to a provider who is reimbursed under a retrospective payment system.
  • The claim is related to a Medicare claim which has been filed in a timely manner, and the Medicaid claim is filed within six months of the disposition of the Medicare claim.
  • Medicaid has suspended payment to the provider during an investigation, and the investigation exonerates the provider.
  • The payment is in accordance with a court order to carry out hearing decisions or agency corrective actions taken to resolve a dispute or to extend the benefits of a hearing decision, corrective action, or court order to others in the same situation as those directly affected by it.

The procedures for the submission of these claims are the same as previously outlined. The required documentation should be written confirmation that the reason for the delay meets one of these specified criteria.