Updates to Chapter 5 of the Hospital Manual
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The purpose of this memorandum is to inform hospital providers of updated language regarding readmission billing. Claims for a patient who is discharged from a facility and readmitted within 6-30 days from date of discharge to the same facility within the same or similar principal diagnosis (locator code 67 on the UB-04) will be considered as a readmission subject to reimbursement reduction. The discharge on the first admission must occur on or after July 1, 2020. A diagnosis is considered same or similar if the first three digits on the diagnosis are the same.
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. Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. 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. 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 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 Aetna Better Health of Virginia https://www.aetnabetterhealth.com/virginia/providers/index.html 1-800-279-1878 Anthem HealthKeepers Plus 1-800-901-0020 Molina Complete Care 1-800-424-4524 https://www.molinahealthcare.com/providers/va/medicaid/home.aspx Sentara Community Plan 1-800-881-2166 https://www.sentarahealthplans.com/providers United Healthcare 1-844-284-0149 Dental Provider DentaQuest 1-888-912-3456 Fee-for-Service (POS) Prime Therapeutics https://www.virginiamedicaidpharmacyservices.com/ 1-800-424-4046 Acentra Health Behavioral Health and Medical Service Authorizations https://vamedicaid.dmas.virginia.gov/sa 1-804-622-8900 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. Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. 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. 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 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 Aetna Better Health of Virginia https://www.aetnabetterhealth.com/virginia/providers/index.html 1-800-279-1878 Anthem HealthKeepers Plus 1-800-901-0020 Molina Complete Care 1-800-424-4524 https://www.molinahealthcare.com/providers/va/medicaid/home.aspx Sentara Community Plan 1-800-881-2166 https://www.sentarahealthplans.com/providers United Healthcare 1-844-284-0149 Dental Provider DentaQuest 1-888-912-3456 Fee-for-Service (POS) Prime Therapeutics https://www.virginiamedicaidpharmacyservices.com/ 1-800-424-4046 Acentra Health Behavioral Health and Medical Service Authorizations https://vamedicaid.dmas.virginia.gov/sa 1-804-622-8900
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.
Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. | |
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. | |
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 | |
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 |
Aetna Better Health of Virginia | https://www.aetnabetterhealth.com/virginia/providers/index.html 1-800-279-1878
|
Anthem HealthKeepers Plus | 1-800-901-0020
|
Molina Complete Care
| 1-800-424-4524 https://www.molinahealthcare.com/providers/va/medicaid/home.aspx
|
Sentara Community Plan | 1-800-881-2166 https://www.sentarahealthplans.com/providers
|
United Healthcare | 1-844-284-0149
|
Dental Provider DentaQuest | 1-888-912-3456 |
Fee-for-Service (POS) Prime Therapeutics
| https://www.virginiamedicaidpharmacyservices.com/ 1-800-424-4046 |
Acentra Health Behavioral Health and Medical Service Authorizations | https://vamedicaid.dmas.virginia.gov/sa 1-804-622-8900 |