Updated Private Duty Nursing Regulations and Forms
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The purpose of this bulletin is to notify providers about the following regulation and form changes effective March 26, 2026 which:
- Clarify that private duty nursing is not a covered service unless an individual is authorized for medically necessary private duty nursing as an Early, Periodic Screening, Diagnosis, and Treatment (EPSDT) service or as a 1915 (c) waiver service.
- Create a new regulation, 12VAC30-50-132, that includes a service description, list of service components, provider qualifications, and service limits.
- Add a revised DMAS-62 Medical Necessity Assessment and Private Duty Nursing Service Authorization Form, including a new Medical Needs Assessment algorithm, to the 12 VAC30-50 FORMS list.
Regulations related activities can be found at: https://townhall.virginia.gov/stageid=10278
The attached DMAS-62 form, noted as “Effective March 26, 2026,” is posted on the Service Authorization Related Forms webpage and required for all service requests June 5, 2026 and forward.
Additional guidance on the document transition is located at:
https://vamedicaid.dmas.virginia.gov/sites/default/files/2026-06/2026_05_DMAS62_FAQ.pdf
For fee-for-service requests for members not enrolled in a 1915(c) Developmental Disability Waiver, the completed DMAS-62 and supporting clinical documentation must be submitted through the Atrezzo portal at https://atrezzo.acentra.com.
For fee-for-service requests for members enrolled in 1915(c) Developmental Disability waivers, the completed
DMAS-62 and supporting clinical documentation must be submitted through the Waiver Management System (WaMS).
Cardinal Care requests for members enrolled in a Managed Care Organization (MCO) must be submitted to the member’s assigned MCO.
DMAS is refining applicable provider manual guidance to be consistent with the regulatory action changes.
Webinars reviewing the updated DMAS-62 will be held on the following dates:
June 12, 2026, at 12:00 p.m. EST Virginia Regulatory Town Hall View Meeting
June 18, 2026, at 12:00 p.m. EST Virginia Regulatory Town Hall View Meeting
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 | |
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 Prior Auth requests can be faxed or called to the following numbers: Phone: 1-800-279-1878 Med4/ FAMIS Fax: 1-866-669-2454 CCC Plus Fax: 1-855-661-1828 |
Anthem HealthKeepers Plus | Prior Authorization information can be found here: https://providers.anthem.com/virginia-provider/resources/prior-authorization-requirements Call Provider Services: 1-800-901-0020 TTY: 711 Fax medical prior authorization request forms to: Inpatient fax: 1-866-920-4095 Outpatient fax: 1-800-964-3627 LTSS fax: 1-844-864-7853 |
Humana Healthy Horizons Provider Services Call Center | https://provider.humana.com/medicaid/virginia-medicaid Prior Authorization information can be found here: https://provider.humana.com/medicaid/virginia-medicaid/prior-authorization Submit request via Availaty porta, phone or fax: Phone requests: 1-855-223-9868 or 1-844-881-4482 (TTY: 711) Fax complete form to: 1-877-486-2621. |
Sentara Community Plan | 1-800-881-2166 https://www.sentarahealthplans.com/providers Submit authorizations via portal or phone Portal information can be found here: https://www.sentarahealthplans.com/en/providers/claims-authorizations/authorizations Phone request: 1-757-552-7474 or 1-800-229-8822 |
United Healthcare | 1-844-284-0146 To notify UHC or request a medical prior authorization: Portal information can be found here: UHCprovider.com/priorauth or call provider services 1-844-284-0146 |
Acentra Health Behavioral Health and Medical Service Authorizations | https://vamedicaid.dmas.virginia.gov/sa 1-804-622-8900 |
Dental Provider DentaQuest | 1-888-912-3456 |
Fee-for-Service (POS) Prime Therapeutics
| https://www.virginiamedicaidpharmacyservices.com/ 1-800-932-6648 |