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Virginia Premier Health Plan Effective October 1, 2009 Exits From Six (6) Localities –

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Effective Date:

All Providers and Managed Care Organizations (MCOs) participating in the impacted localities/surrounding areas in the Virginia Medical Assistance Programs
Patrick W. Finnerty, Director DMAS


The purpose of this memorandum is to inform you of changes to the Medicaid/FAMIS Managed Care program, effective October 1, 2009. Virginia Premier Health Plan, Inc. notified DMAS that they will be leaving six (6) localities effective October 1, 2009. The localities include:


Caroline County                                 Culpeper County

Madison County                                 Orange County

Rappahannock County                       Warren County


Caroline, Madison, Orange, Rappahannock and Warren Counties

For individuals enrolled in Medicaid and FAMIS Plus (Children’s Medicaid) in the localities of Caroline, Madison, Orange, Rappahannock and Warren, the normal pre-assignment process will take place to ensure that all waiver requirements (including MCO choice) are met. As a result, Medicaid individuals enrolled in Virginia Premier in these localities at the end of September will go to fee-for-service as of October 1, 2009. They will receive services through Medicaid's fee-for-service program until the pre- assignment and assignment processes are completed. Enrollment into a new health plan will not be effective until December 1, 2009. Depending on the MCO option in each locality, members will be able  to choose between at least two of the following: Anthem Healthkeepers Plus, Optima Family Care, Southern Health/CareNet and/or AMERIGROUP Community Care. Please refer to the DMAS website under Managed Care at for health plans participating in your area prior to and/or after October 1, 2009.


Individuals enrolled in the FAMIS or FAMIS MOMS programs in these localities will be moved from Virginia Premier to another health plan effective October 1, 2009, with no break in managed care



coverage. FAMIS families may contact the FAMIS Central Processing Unit (CPU) at 1-866-87FAMIS with questions.


Culpeper County

For Medicaid/FAMIS Plus enrolled individuals residing in Culpeper, only AMERIGROUP will be contracted to provide services in this area, effective October 1, 2009. The Federal Managed Care regulations give DMAS the authority to operate managed care using a single MCO system in a Federally designated "rural" area. Refer to Federal guidelines at 42CFR438.52(b) for more information. Culpeper County meets this rural designation and therefore another health plan choice is not required in Culpeper. All other program exclusions and operating criteria apply.


Beginning October 1, 2009, individuals residing in Culpeper will receive their Medicaid managed care coverage through AMERIGROUP Community Care. The enrollment of Culpeper's Virginia Premier Health Plan membership into AMERIGROUP Community Care is expected to be a smooth transition, moving the individuals directly from Virginia Premier to AMERIGROUP effective October 1, 2009. A letter was sent to the affected individuals the end of August to inform them of this change.


FAMIS or FAMIS MOMS enrolled individuals residing in Culpeper will also be automatically enrolled with AMERIGROUP beginning Oct. 1, 2009. FAMIS families may contact the FAMIS CPU at 1-866- 873-2647 with questions or for disenrollment options.


Newborn Coverage for All Six (6) Localities

Consistent with existing guidelines, for all six (6) localities, newborns born on or before September 30, 2009 to Virginia Premier Medicaid and FAMIS* enrollees, will be covered for the birth month plus two additional months under Virginia Premier. Therefore, providers rendering services to babies born on or before September 30, 2009 (to Virginia Premier enrolled mothers) should bill Virginia Premier where the date of service falls within the birth month plus 2 timeframe. (*Note: birth month plus two coverage is not available under the FAMIS MOMS program.)


Impact on Providers

Beginning October 1, 2009, managed care individuals residing in Culpeper must receive their Medicaid coverage through AMERIGROUP Community Care. Members receiving certain services from a non- participating provider will be allowed to receive services out of network for at least 60 days in order to transition to an AMERIGROUP participating provider. An out of network (OON) referral must be requested from AMERIGROUP for these services to be covered. If you are not already contracted with AMERIGROUP, DMAS encourages providers to contact provider services at this MCO by calling AMERIGROUP Community Care at 1-800-454-3730.


For other localities and MCO provider services contact information, refer to numbers listed below:


Anthem Healthkeepers Plus


Optima Family Care


Southern Health/CareNet




Providers should verify eligibility at each point of service. Eligibility verification information is provided at the end of this memo.


Impact on Enrollees

All affected individuals have been notified via letter of these changes. Medicaid/FAMIS Plus recipients may contact the Managed Care HelpLine at 1-800-643-2273 (TDD: 1-800-817-6608) or find more information about Managed Care at on the DMAS website. FAMIS enrollees should contact the FAMIS CPU at 1-866-873-2647 (TDD: 1-888-221-1590) for assistance with choosing a MCO.



In an effort to reduce operating expenditures, requests for duplicate provider remittance advices will no longer be printed and mailed free of charge. Duplicate remittance advices will be processed and sent via secure email. A processing fee for generating duplicate paper remittance advices will be applied to paper requests, effective July 1, 2009.



Effective August 1, 2009, DMAS authorized users now have the additional capability to look up service limits by entering a procedure code with or without a modifier. Any procedure code entered must be part of a current service limit edit to obtain any results. The service limit information returned will pertain to all procedure codes used in that edit and will not be limited to the one procedure code that is entered.  This is designed to enhance the current ability to request service limits by Service Type, e.g., substance abuse, home health, etc. Please refer to the appropriate Provider Manual for the specific service limit policies.



DMAS has contracts with the following eligibility verification vendors offering internet real-time, batch and/or integrated platforms. Eligibility details such as eligibility status, third party liability, and service limits for many service types and procedures are available. Contact information for each of the vendors is listed below.


Passport Health

SIEMENS Medical Solutions –


Communications, Inc.

Health Services

Foundation Enterprise

Telephone: 1 (877) 363-3666



Telephone: 1 (888) 661-5657



Telephone: 1 (610) 219-2322




DMAS offers a web-based Internet option (ARS) to access information regarding Medicaid or FAMIS eligibility, claims status, check status, service limits, prior authorization, and pharmacy prescriber identification. The website address to use to enroll for access to this system is The MediCall voice response system will provide the same information and can be accessed by calling 1- 800-884-9730 or 1-800-772-9996. Both options are available at no cost to the provider.




DMAS publishes electronic and printable copies of its Provider Manuals and Medicaid Memoranda on  the DMAS website at Refer to the “DMAS Content Menu” column on the left- hand side of the DMAS web page for the “Provider Services” link, which takes you to the “Manuals, Memos and Communications” link. This link opens up a page that contains all of the various communications to providers, including Provider Manuals and Medicaid Memoranda. The Internet is the most efficient means to receive and review current provider information. If you do not have access to the Internet or would like a paper copy of a manual, you can order it by contacting Commonwealth-Martin at 1-804-780-0076. A fee will be charged for the printing and mailing of the manuals and manual updates that are requested.



The “HELPLINE” is available to answer questions Monday through Friday from 8:30 a.m. to 4:30 p.m., except on state holidays. The “HELPLINE” numbers are:


1-804-786-6273          Richmond area and out-of-state long distance

1-800-552-8627          All other areas (in-state, toll-free long distance)


Please remember that the “HELPLINE” is for provider use only. Please have your Medicaid Provider Identification Number available when you call.



DMAS is pleased to inform providers about the creation of a new Provider E-Newsletter. The intent of this electronic newsletter is to inform, communicate, and share important program information with providers. Covered topics will include changes in claims processing, common problems with billing, new programs or changes in existing programs, and other information that may directly affect providers. If  you would like to receive the electronic newsletter, please sign up at enewsletter.asp.


Please note that the Provider E-Newsletter is not intended to take the place of Medicaid Memos, Medicaid Provider Manuals, or any other official correspondence from DMAS.