Nursing Facility Manual Chapter 4
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The purpose of this memo is to notify providers of the changes to Chapter 4 of the Nursing Facility manual. Changes were made to this chapter to update sections related to Cardinal Care managed care nursing facility member enrollment processes, screening, and patient pay requirements. These changes include: 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
These changes include:
- MCO member enrollment process updates
- Eligibility redeterminations
- Electronic LTSS screening (EMLS) updates
- “Telephonic Pre-authorization in emergencies” section has been removed.
- 90-day period added for incurred medical/remedial care
- Expanded justification criteria for patient pay adjustments
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 |