MCO Provider Network Resources
MCO Provider Network news and resources...
Important Information for Managed Care Network Providers
The Federal law known as the 21st Century Cures Act requires all providers to enroll and periodically revalidate directly with DMAS through its provider services solution (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. Dentists do not need to enroll in PRSS and should continue to enroll with the DMAS Dental Benefits Administrator, DentaQuest. For more information, contact DentaQuest Recruitment: 855-873-1283 or email NetworkDevelopment@dentaquest.com.
PRSS remains open for providers required to enroll and who have not applied. Virginia Medicaid MCOs have issued provider terminations for network providers not enrolled in PRSS. Providers who have received termination letters will not have their network participation status reinstated with the MCOs until they enroll in PRSS.
Three 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 submit your application through PRSS, you should request a retroactive effective date to cover any dates of service for care or services you have rendered to Medicaid members.
When you visit the enrollment website, go to the menu drop down in the left corner and select the appropriate "Provider Enrollment" link from the Menu to submit a new enrollment application or to revalidate. 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. MCO network providers will need to periodically revalidate in PRSS in the future.
2. Contract with the MCO
In order to be a Medicaid provider in an MCO's network, providers must first enroll through PRSS and also contact the MCO(s) you wish to participate in to ensure each MCO’s requirements are satisfied. If you have questions regarding how to submit your application to the MCO or your MCO participation (PAR) status, including your MCO PAR status reflected in PRSS, contact the MCO using the information in the table below.
3. Check your enrollment status
All providers should check the Provider Extract spreadsheet (link below), which lists all active, enrolled Virginia Medicaid providers and zip codes for related service locations. Providers can download the file and use the spreadsheet to see if all of their NPIs and service locations are enrolled
Provider Extract Spreadsheet (.XLSB)
(Note: This file can be opened with Microsoft Excel version 2007 or later and is updated at the beginning of each work week). Dental providers will not be listed in the extract. Dental providers should enroll directly with DentaQuest, see contact information in the table below. Click here for more information about this type of Excel file.
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).
If you need assistance or have questions...
If you have questions about the content in the provider extract spreadsheet file (link above), your NPI(s), or about the Virginia Medicaid Provider enrollment process? Please contact DMAS' PRSS vendor, Gainwell, at 1-888-829-5373, or by email: vamedicaidproviderenrollment@gainwelltechnologies.com
If you have questions regarding your MCO participation (PAR) status, including your MCO PAR status reflected in PRSS, contact the MCO using the information in the table below.
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
MCO Provider Network Management Contacts to: 1) Answer provider questions on MCO Participation Status reflected in PRSS or 2) Learn How to Contract/Credential with MCOs | |
| Aetna | https://www.aetnabetterhealth.com/virginia/providers/join-network.html |
| Anthem | LTSS - VALTSSProviderEnrollment@anthem.com. Providers with questions about their enrollment status should contact their assigned PR rep. The contact list is currently on DMAS site or can be accessed on Anthem’s website: https://providers.anthem.com/virginia-provider/join-our-network by clicking LTSS Provider Relations Staff Non-LTSS - https://www.anthem.com/provider/contact-us/ Under “Additional Support” providers can select the appropriate contact by provider type |
| Molina | Become a Molina Healthcare Network Provider by visiting: https://www.molinahealthcare.com/providers/va/medicaid/network/join-our-network.aspx |
| Optima | Provider Network Management - 1-877-865-9075 Email: PrvRecruit@sentara.com |
| UnitedHealthcare | Join Our Network | UHCprovider.com Provider Services: 1-844-284-0146 |
| DentaQuest (DMAS Dental Benefits Administrator) | DentaQuest Recruitment: 855-873-1283 or NetworkDevelopment@dentaquest.com |
| Note: DMAS/Gainwell staff are not able to update the provider's contract participation status for MCOs. MCO Network affiliation is managed by the MCOs. | |
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)