Update to Chapter II of the Hospice and Nursing Facilities Provider Manual

Memo

January 6, 2026, 9:53AM

To:

All Hospice Providers, All Skilled Nursing Facility Providers Participating in the Virginia Medical Assistance Program, Managed Care Organizations, and Holders of the Hospice Provider Manual

From:

Cheryl J. Roberts, Director Department of Medical Assistance Services (DMAS)

The purpose of this memorandum is to highlight changes to the Department of Medical Assistance Services (DMAS) made to Chapter II of the Hospice Manual and the Nursing Facilities Manual.

Risk Screening Requirements for Hospice Providers Effective December 1, 2025

In accordance with Section 6401(a) of the Affordable Care Act (ACA) and 42 CFR § 455 Subpart E, beginning on December 1, 2025, Hospice providers must undergo:

• High-risk screening for initial enrollment, re-enrollment, and changes in ownership

• Moderate-risk screening for revalidations

The requirements are shown in the chart below:

Screening Activities by Risk Level

Limited Risk

Moderate Risk

High Risk

Verification that a provider or supplier meets any applicable Federal regulations, or State requirements for the provider or supplier type prior to making an enrollment determination.
Verification that a provider or supplier meets applicable licensure requirements; and
Federal and State database checks on a pre- and post-enrollment basis to ensure that providers and suppliers continue to meet the enrollment criteria for their provider/supplier type and that they are not excluded from providing services in federally funded programs.

√

Unannounced pre-and/or post-enrollment site visits to confirm accuracy of information submitted in the provider’s application.

Not Applicable

√

Criminal background check(s) and submission of fingerprints of the provider, including person with a 5% or more ownership interest.

Not Applicable

√

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.

PROVIDER CONTACT INFORMATION & RESOURCES

Virginia Medicaid Web Portal Automated Response System (ARS)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

https://vamedicaid.dmas.virginia.gov/

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

Provider Appeals

DMAS launched an appeals portal in 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/appeals/

Managed Care Programs

Cardinal Care Managed Care 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.

Cardinal Care Managed Care

https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-…

PACE

Program of All-inclusive Care (virginia.gov)

Provider Enrollment

In-State: 804-270-5105

Out of State Toll Free: 888-829-5373

Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com

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