Patient Pay Underpayments Have Been Stopped

Download PDF

Bulletin

July 26, 2023, 10:09AM

To:

All Providers and Managed Care Organizations Participating with the Medicaid/FAMIS Programs

From:

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

The purpose of this bulletin is to notify long term services and supports providers that DMAS has issued a broadcast notice to local departments of social services that staff should immediately stop calculating patient pay underpayments for nursing facility residents.

The broadcast notice is based on recent guidance from CMS, and it contains the following information:

Patient Pay Underpayments:

should no longer be calculated, and
should no longer be referred to the DMAS Recipient Audit Unit for recovery.

Patient pay increases must occur prospectively and only after the member receives an advanced notice with appeal rights. Adjustments must be completed at renewal for those cases that are not in a current certification period [cases with an overdue renewal date]. Staff must immediately stop calculating underpayments or running retro-cancel-reinstate to capture underpayments in the past. DMAS is determining how to run a report of any underpayments that have been calculated since April 1, 2023, since those cases will need to be corrected. LTSS Renewal Training and the fact sheet will be revised with this new information. Policy in M1470.900 will be updated in a future transmittal.

Example: Nursing home client renewal is overdue and will be completed by 09/2023 per the calendar schedule. The member submits the renewal on 8/16/2023. The current patient pay amount did not include COLA increases for 2021, 2022 or 2023 per PHE procedures. The patient pay should be adjusted using the 2023 income amount moving forward effective the first month after the member has been given 10 days advance notice.

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