MCO Provider Network news and resources...

New!  Important Deadline for Managed Care Network Providers

Take Action Now to Avoid Payment Delays: Effective April 1, 2023, Virginia Medicaid MCOs will begin to initiate provider terminations and/or payment suspensions for network providers until the provider is enrolled with the Virginia Department of Medical Assistance Services (DMAS) through the Provider Services Solution (PRSS) portal.   At this time, the MCO will continue payments to providers who have initiated the process and have a pending application in PRSS.

The Federal law known as the 21st Century Cures Act requires all providers to enroll directly with the DMAS through its PRSS portal.  This requirement includes billing, servicing, Ordering, Referring, or Prescribing (ORP) providers who serve members through managed care organizations (MCOs) or Fee-For-Service (FFS), or both.

Two Action Items for Providers:

1.   Enroll in PRSS

We value your participation!  If you have not enrolled in PRSS, please visit virginia.hppcloud.com to initiate this mandatory enrollment process now to avoid disruption to claims payments.  When you visit the enrollment website, go to “Enroll as a new provider or check your enrollment status.”  Only one enrollment application is necessary in PRSS, even if a provider participates with more than one MCO.  Providers with multiple National Provider Identifier (NPI) numbers must enroll all of their NPIs in PRSS.  Providers with multiple service locations must enroll all locations.

In order to be a provider in an MCO's network, providers must first enroll through PRSS and then contact the MCO(s) you wish to participate in to ensure each MCO’s requirements are satisfied.  MCO Provider Network Management Contact information is provided in the Important Links section below.  MCO network providers who are already actively enrolled with Medicaid fee-for-service (FFS) do not need to re-enroll in PRSS.

2.   Check your enrollment status

All providers should check the Provider Extract spreadsheet (link below), which lists all active, enrolled Virginia Medicaid providers.  Providers can download the file and use the spreadsheet to see if all of their NPIs and service locations are enrolled. 
Provider Extract Spreadsheet (.XLSX) 
(This list is updated at the beginning of each work week)

Action Item: If any of the provider’s NPIs or service locations are missing, the provider must enroll the missing NPI or service locations using the PRSS portal (see above to enroll).

Important Links

• PRSS Enrollment and Instructions for this mandatory process:  virginia.hppcloud.com
• Helpful training resources available on the MES website:  vamedicaid.dmas.virginia.gov/training/providers
• Questions about the content in the file, your NPI(s), or about the Virginia Medicaid Provider enrollment process?  Please contact the PRSS vendor, Gainwell, at 1-888-829-5373, or by email:  vamedicaidproviderenrollment@gainwelltechnologies.com

Search the MES Public Portal:

MCO Toolkit (Updated February 2023)

Download the MCO Toolkit (PDF)

Guidance for EI FQHC RHC CSB ORP and OOS Providers (MCO Only)

Guidance for EI FQHC RHC CSB ORP and OOS Providers (PDF)