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This memorandum is being issued to notify providers of recent revisions to Chapter II of All Provider Manuals that clarify certain Medicaid billing requirements and appeal procedures. 

Billing Requirement Clarifications and General Updates

Chapter II of the Provider manuals is being updated to:

•         Clarify provider enrollment information for out-of-state providers.

•         Reaffirm that all medical providers must bill Virginia Medicaid, or the appropriate contracted Managed Care Organization based on a member’s enrollment, for any and all covered medical services furnished to an eligible Medicaid member. These revisions further clarify that providers and their vendors, or billing agents may not seek reimbursement from non health insurance plans or carriers; including, but not limited to, vehicular insurance (such as Medical Payments Coverage or Liability Coverage), property insurance, or other funds associated with a Medicaid member’s tort claims, for services covered by Medicaid. Consistent with Medicaid’s payor of last resort requirements, such non health insurance resources are not appropriate sources of payment for covered medical services. 

•         Additional minor text changes have been made to streamline the language throughout the chapter and improve readability.

Appeals Procedural Updates

In 2025, the General Assembly directed DMAS to promulgate regulations to require providers to file their appeals online.  These regulations went into effect on November 5, 2026. Chapter II of all Provider Manuals has been revised to conform with these regulations.

The Appeals Information Management System (“AIMS”) is the Appeals Division’s online portal.  AIMS allows providers to file new appeals, upload documents, and track the status of appeals.  Information about AIMS and the provider appeal process is available on the Appeals Division webpage.  Providers must register for AIMS in order to file appeals online as required by the regulations and Manual update.

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.