Va. DMAS Hospice Provider Manual ch. V, Introduction

The purpose of this chapter is to explain the procedures for billing the Virginia Medicaid

Program (Medicaid) for covered services provided to Medicaid-eligible individuals. The

Department of Medical Assistance Services (DMAS) is the agency that oversees

Medicaid in the Commonwealth of Virginia.

This chapter will address:

•

General Information - This section contains information about DMAS’ claims

systems and requirements, including timely filing and the use of appropriate claims

forms.

•

Billing Procedures – This section provides instructions on completing claim

forms, submitting adjustment requests, and additional payment services.

This manual chapter primarily relates to fee-for-service billing. For more information about

reimbursement and claims processing instructions for an individual in a managed care

organization, please contact the managed care organization (MCO) directly. Providers

must be credentialed with a member’s MCO in order to bill for services provided to that

member.

Providers under contract with the Program of All-Inclusive Care (PACE) should contact

the

PACE

Program

for

billing

information.

For

additional

details

see

https://www.dmas.virginia.gov/for-providers/long-term-care/programs-and-

initiatives/program-of-all-inclusive-care/.

FEE SCHEDULE

A fee schedule is a complete listing of fees used by Medicaid fee-for-service to pay

providers for most services to include professional claims. DMAS develops the fee

schedule and can be found on the DMAS website,

https://www.dmas.virginia.gov/for-providers/rates-and-rate-setting/.

Managed Care Organizations (MCOs) must reimburse providers in accordance with the

individual provider's contract with the MCO. There are specified services which require

the MCO to pay FFS reimbursement rates or to pay providers at a certain percentage

of the FFS rate. MCO rules for provider payments are explained in the Cardinal Care

Managed Care Contract, Chapter 12, Provider Payment, available on the DMAS website

@ Cardinal Care Managed Care.