Processing and Payment of Emergency Room Claims Effective April 27, 2023

Bulletin

June 29, 2023, 10:41AM

To:

All Hospitals and Physicians Participating in the Virginia Medical Assistance Program and Managed Care Organizations (MCOs)

From:

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

The purpose of this bulletin is to notify providers of changes to the processing and payment of claims submitted for specific emergency room (ER) services. The applicable procedural terminology (CPT) codes used to describe patients’ visits to the hospital ERs are 99282, 99283, or 99284.

Effective for dates of service on and after April 27, 2023, pursuant to a federal court order (Va. Hosp. & Healthcare Assoc. et al. v. Roberts et al., No. 3:20-cv-00587-HEH), DMAS and the MCOs will no longer enforce Item 313.AAAAA of the 2020 Acts of Assembly (Downcoding Provision):

The Department of Medical Assistance Services shall amend the State Plan for Medical Assistance Services to allow the pending, reviewing and the reducing of fees for avoidable emergency room claims for codes 99282, 99283 and 99284, both physician and facility. The department shall utilize the avoidable emergency room diagnosis code list currently used for Managed Care Organization clinical efficiency rate adjustments. If the emergency room claim is identified as a preventable emergency room diagnosis, the department shall direct the Managed Care Organizations to default to the payment amount for code 99281, commensurate with the acuity of the visit. The department shall have the authority to implement this reimbursement change effective July 1, 2020, and prior to the completion of any regulatory process undertaken in order to effect such change.

The Downcoding Provision has been removed from all MCO contracts effective April 27, 2023 and will be removed from applicable regulations and manuals. DMAS and the MCOs are implementing the necessary system changes required to remove the Downcoding Provision and reprocess previously submitted claims impacted by this change for dates of service from April 27, 2023 forward in the fee-for service and managed care programs. Providers will not need to resubmit these claims. Once system changes are complete, new timely claims submitted for dates of service from April 27, 2023 forward will be processed without the Downcoding Provision.

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

Acentra Health

Service authorization information for fee-for-service members.

https://dmas.kepro.com/

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

Medallion 4.0, Commonwealth Coordinated Care Plus (CCC Plus), 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.

Medallion 4.0

http://www.dmas.virginia.gov/#/med4

CCC Plus

http://www.dmas.virginia.gov/#/cccplus

PACE

http://www.dmas.virginia.gov/#/longtermprograms

Magellan Behavioral Health

Behavioral Health Services Administrator, check eligibility, claim status, service limits, and service authorizations for fee-for-service members.

www.MagellanHealth.com/Provider

www.magellanofvirginia.com, email: VAProviderQuestions@MagellanHealth.com,or

Call: 1-800-424-4046

Provider Enrollment