Waiver Claims Issues

September 14, 2016

While we appreciate the efforts of the DBHDS staff to finally complete the task of entering the SIS Levels/Tiers which are necessary to permit billing for Group Home services (H2022); we certainly recognize the hardship imposed on the providers who can not bill.  While DBHDS will not respond to individual requests, we would advise that providers process claims on the provider’s schedule (claims entered by 5pm on Friday will pay, if all data elements are present, on the following Friday night).  In order to plan cashflow, you can confirm on Monday which claims entered the previous Friday will or will not pay.

In-Home claims (H2014) are also being denied; this is a problem within the VaMMIS system and will be resolved as quickly as possible by DMAS staff.  We will try to inform you when/how claims will be paid.

Provider Enrollment has turned into a major problem as the “rules” for submission seem to have changed since the Memo of 9/1/16 was published.  The enrollments already submitted to permit “new” services are being rejected and providers are getting a letter which provides little useful information.  We expect this to be “fixed” without any further action on the part of the provider; we expect additional information by tomorrow.  Print the letter sent to your secure email account on the Medicaid WebPortal for a record of the Enrollment rejection.

There are ongoing questions about “periodic supports” which are not permitted (except for sponsored residential through 31 December).  The biggest issue seems to be with “In-Home” services.  The service plans currently in place should contain the elements necessary to support a service authorization request to increase the In-Home hours to permit supports being provided at those times when an individual may not be able to participate in other activities.  We will post a more comprehensive description on the Implementation page in the morning.