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Information for healthcare professionals
Join the Virginia Premier Network
We’re always looking for healthcare professionals who share our commitment to providing plan members with quality, safe and cost-efficient care.
Update Your Information
Need to update Virginia Premier about changes to your provider information? Let us know about changes.
Contact Provider Relations
Email our Provider Relations Team at contactmyrep@virginiapremier.com Monday through Friday.
Provider News
Optima Health/Virginia Premier Merger
NationsBenefits, LLC Breach
New Pharmacy Benefit Manager Coming In 2023
Portal Log In
Recent Provider Notices
- Provider Notice-Virginia Premier Announces Selection of New PBM
- Provider Notice-Vision Vendor Change
- Provider Notice-Federally Funded Title X Family Planning Services
- Provider Notice-Enroll in PRSS to Continue Receiving Medicaid Payments
- Provider Notice-Member ID Cards Updated for 2023
- Provider Notice-Updates to Nursing Facility Contacts
- Provider Notice-Process Changes for the Addiction and Recovery Treatment Service (ARTS)
- Provider Notice-Virginia Premier Will Implement New Medical Payment Policies on Feb 1
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Provider Notice-Virginia Premier Announces Selection of New PBM
- Provider Notice-Virginia Medicaid Regulatory Updates to Provider Agreements
- Announcing Changes to the Credentialing Process For Crisis Services
- Zelis to Provide Claims Review
- COVID-19 Support Payments
- Extension of Medicaid Coverage for New Moms
- Virginia Premier Partnering With Cotiviti To Complete Claims Audits
- Partnership with DarioHealth Supports Members with Type 2 Diabetes
- Changes to Hearing Benefit for Pediatric Patients Take Effect October 1
- PRSS Portal Update Enrollment Outreach Begins Soon For MCO Providers
- Connecting Members with Support After a Hospital Stay
- Registering with Virginia Premier for Secured Faxes
- Connecting Your Patients With Support
- Virginia Premier Launching Doula Benefit for Pregnant Members
- New Fax Line for Service Authorization Requests
- COVID-19 Provider Update (Medicare Discharge)
- Service Facilitation Limits and Authorizations
- COVID-19 Provider Update (Service Authorizations)
- COVID-19 Provider Update
- Online Claim Reconsiderations
- New Provider Portal and Prior Authorization List Tools Available
- LTSS Screening Requirements for Nursing Facilities
- Best Practices for Submitting Claims with Authorizations
- Hospice Room and Board Reimbursement
- Operational Excellence
- LTSS Screening Requirements and Associated Claims Reimbursement
- Electronic Claim Submission
- Readmission Payment Policy
- Billing Guidelines Policy
- List of HCI Edits
- Vendor Transition
Form Library
- W9 Completed form must be included with electronic funds transfer forms for processing.
- Claim Adjustment Form Providers who want to appeal a claim outcome, submit a corrected claim or request a retraction due to a payment error should use the Claim Adjustment form.
- Provider Refund Form The Provider Refund Form will assist Virginia Premier with handling your refund inquiries expeditiously. Please ensure all fields on the form are completed along with attached detailed information explaining the reason for the refund.
ARTS Provider Attestation Forms
ASAM 2.1 – 3.7 Attestation ARTS OBOT Attestation ARTS OTP Attestation- EDI 837 (Electronic) Claims Enrollment Form
In order to submit your claims electronically through a clearinghouse, you must first complete and submit the Virginia Premier EDI 837 Claims Enrollment form. Download PDF form. - W9
Completed form must be included with electronic funds transfer forms for processing. - Claim Adjustment Form
Providers who want to appeal a claim outcome, submit a corrected claim or request a retraction due to a payment error should use the Claim Adjustment form. - Provider Refund Form
The Provider Refund Form will assist Virginia Premier with handling your refund inquiries expeditiously. Please ensure all fields on the form are completed along with attached detailed information explaining the reason for the refund.
- Provider Update Request Form
Are you already a participating provider for Virginia Premier and need to notify us for updates or changes to your office or provider information such as address, phone or providers? Please use this page to submit changes to Virginia Premier. - Panel Change Request Form
Are you a participating PCP and would like to close or open your member panel? Please use this form to notify Virginia Premier of your request.
- Recruitment Request Form
Are you a physician or healthcare provider interested in joining the Virginia Premier network? Please fill out Recruitment Request form to request participation in the Virginia Premier network. - Transportation Recruitment Request Form
Complete this form when requesting a vendor to be recruited, or when receiving a call from an interested vendor. - Provider Update Request Form
Are you already a participating provider for Virginia Premier and need to notify us for updates or changes to your office or provider information such as address, phone or providers? Please use this page to submit changes to Virginia Premier. - Panel Change Request Form
Are you a participating PCP and would like to close or open your member panel? Please use this form to notify Virginia Premier of your request.
- Newborn Notification Form
- PCP Change Request Form
If you are a PCP and have members who would like to notify Virginia Premier of their wish to change their PCP, please print the PCP Change form and have members complete this form and fax to Virginia Premier. - Care Management Request Form
- Wellness Request Form
- Authorization Request for Inpatient and Outpatient ServicesProviders should use this form when requesting authorization for a procedure to be performed in an IP/OP or OBS setting.
- DME Prior Authorization FormProviders should use this form when requesting authorization for durable medical equipment.
- Outpatient Treatment Report (Behavioral Health)
Behavioral Health providers should complete and fax this form to request authorization for additional visits beyond the initial approved. - OB Registration Form
This form should be completed for all obstetrical patients assigned to Virginia Premier. Care Management teams use this information to educate members and coordinate care. - ESPDT Medical Needs Assessment
This form should be completed to summarize daily medical needs to determine eligibility for Early Periodic Screening Diagnosis and Treatment nursing. A physician, PA or nurse practitioner must sign the form. - Alere Referral
- ARTS Initial Service Authorization Request Form
- ARTS Extension Service Authorization Form
- ARTS Registration Form for Substance Use Case Management
Formulary
- Medical Drug Authorization Changes – Effective 7/1/2023
- 2023 Medicaid Formulary (FAMIS)
- 2023 Medicaid Formulary
- 2023 Medicaid Prior Authorization Detail
Medallion Members
Commonly Used Coverage Determination Forms
- Compound Drug Prior Authorization Form
- Weight Management Prior Authorization Form
- Growth Hormone Prior Authorization Form
- Hep C Non Preferred Prior Authorization Form
- Medical Necessity Prior Authorization Form
- Non-Formulary Exception Request
- Opioid Prior Authorization Form
- Opioid Non-Preferred Prior Authorization Form
- Quantity Limit Prior Authorization Form
- Subutex Prior Authorization Form
- ADHD (AL, AL/NF, NF) Prior Authorization Form
- Preferred Anti-Migraine Prior Authorization Form
- Antipsychotic AL/NF Prior Authorization Form
- Movement Disorder Prior Authorization Form
- Non-Preferred Anti-Migraine Prior Authorization Form
Provider Resources
Virginia Premier has helpful HEDIS-related provider tools that provide you with details about each measure.
Frequently Asked Questions
Q: Does Virginia Premier require referrals to specialists?
Referrals are not required when sending a member to a participating specialist. However, authorization is required if a member is sent to a non-participating provider. Please contact Virginia Premier’s Medical Management Department at 800-727-7536 to obtain a referral for non-participating providers.
Q: Do Virginia Premier members need referrals for routine vision services?
No. Members may see a VSP contracted provider without a referral for routine vision services. For a list of participating providers go to www.vsp.com or by calling 800-852-7600.
Q: Will Virginia Premier accept a DME request written on a prescription pad?
No. Pursuant to Centers for Medicare & Medicaid Services (CMS) all DME requests for supplies and equipment must be submitted on a certificate of medical necessity form (CMN) form for documentation purposes.
Q. Do Virginia Premier members have copays?
Medallion and FAMIS MOMS do not have copays, only FAMIS enrollees have copays for services. Please refer to the member’s ID card for copay amounts or call Virginia Premier’s Member Services department at 800-727-7536. Our policy for Appeals and Grievances for Virginia Premier members can be found here: Appeals and Grievances.
Q. How are PCP’s selected for members?
Virginia Premier members are given the opportunity to select a participating PCP at the time of enrollment. If the member does not select a PCP prior to enrollment, then Virginia Premier will assign a PCP to the member. The member will receive a new member packet and ID card prior to their enrollment start date.
Q: Can we perform labs in our office? If not, which reference lab do Virginia Premier members need to use?
You may perform CLIA waived labs for Virginia Premier members in the office. All other lab tests must be sent to one of Virginia Premier’s contracted labs such as LabCorp or Quest Labs (CCL). All providers who perform CLIA waived labs must submit their CLIA certificate number in box 19 of the CMS1500 claim form in order to receive payment.
Q: I am not sure who my Virginia Premier Provider Service Representative is, how can I find out who s/he is?
You may contact Provider Services at 800-727-7536, option 6 to obtain the name and number of your local Provider Services Representative.
Q: If a member has another PCP’s name on their member ID card, can we still see that member?
Yes. If you are a participating provider with Virginia Premier, you may see that member. Virginia Premier strongly encourages PCP offices to have the member either call and change their PCP during the office visit or to have the member complete a PCP Change Request Form. Forms Library (Medical Management)
Q: Is transportation available to all Virginia Premier enrolled members?
No. Routine transportation is not a covered benefit for FAMIS members. All transportation requests must be received 72 hours prior to the member’s appointment.
Q. What is the time limit for appealing the outcome of a claim?
Appeals for denied claims must be submitted to Virginia Premier within 60 days from the date on the Virginia Premier remit.
Q. Can I submit a reproduced paper claim?
Unfortunately due to our OCR system that scans all paper claims into our claim adjudication system, providers are required to submit new claim forms with red and black ink. We will return any copied claim forms that we receive to the provider with an explanation.
Q: What is considered a “clean claim”?
A “clean claim” is defined as a claim that has no material defect or impropriety (including any lack of any reasonably required substantiation documentation) which substantially prevents timely payment from being made on the claim or with respect to which Virginia Premier has failed to timely notify the person submitting the claim of any such defect or impropriety.
Q: How long does the provider credentialing process take with Virginia Premier?
The credentialing process for providers can take up to 120 days to be processed and completed once an application has been received in the Credentialing Department. There are some instances in which this process can take less time to complete.
Q. Does Virginia Premier participate with CAQH?
Yes we do. Virginia Premier highly encourages all providers to utilize CAQH to simplify the credentialing and re-credentialing process.
Q: I am interested in joining the Virginia Premier network as a provider, what do I need to do?
Providers can apply to be a part of network by doing one of the following:
- Complete the Recruitment Request Form Online or Download it, fill it in and fax it back to us
- Call Provider Services at 800-727-7536, option 6
All requests for participation are reviewed by the Network Development Committee and considered based on the needs of the service area.
Q: Is a provider required to notify Virginia Premier when closing or leaving a practice?
Yes. The Group or Provider is contractually required to give Virginia Premier ninety (90) days advance written notice with a termination date and reason for the provider’s departure. The notice should be sent to:
Virginia Premier Health Plan, Inc.
Attn: Network Development / Contracting Specialist
PO Box 5307, Richmond, VA 23220
Or fax to 804-819-5366
Providers are required to provide thirty (30) days advance notice in writing to members. Members should be advised on how to access their medical records upon closure of the office.
Q: How can I obtain a copy of the provider access standards for participating providers?
The access standards are located in the Virginia Premier Provider Manuals. They are also posted annually in the Provider newsletter as well.
Q: How can I obtain a Provider Manual?
The Virginia Premier Provider Manual can be downloaded online from the Provider Manuals tab on this page. Hard copies are available by contacting Network Development, (800) 727-7536 option 6. If there are any relevant changes they are posted on the website, quarterly Provider newsletters and special notices sent to Providers.
Q. How do I join the Virginia Premier network?
On our website, you will find the link to either complete the form online or download it. If you elect to download the form, be sure to complete it in full and fax it to the Network Development Department at (804) 819-5366. To fill out the form online, please use the link below:
Join Our Network.
Q. When will my Recruitment Request Form be presented to the Network Development Committee?
We conduct the Network Development meeting once a month to review all Recruitment Request Forms that have been submitted during the prior month. This meeting is typically held the first week of each month and we will evaluate most Recruitment Request forms up to that date.
Q. Does my Recruitment Form submission automatically get approved?
No. All providers and groups are presented through the Network Development Committee process.
Q. If my Recruitment Form does get approved to join the Virginia Premier network, then how long will it take to hear back from Contracting for the next steps?
We ask that you allow at least 7-14 days to hear back from us after the Network Development Committee has met. When you are filling out the Recruitment Request Form, please be sure to double check that your physical address and your email address are legible to avoid any potential delays. We will use one or the other to notify you once the Committee decision has been made.
Q. Once our group has been approved and fully credentialed with Virginia Premier, how do I submit changes for provider demographics (i.e., address changes, provider terminations, adding providers or additional locations)?
Please use the following link to submit any changes:
Provider Update Request Changes.
Q. Once I have submitted a Provider Update Request Form for a provider or address change, then how can I validate the change has been made?
Once you have submitted a Provider Update Request Form, then you may validate the completion of your request 15-20 business days after submission via the Virginia Premier Online Provider Directory and/or Online Provider Portal, as applicable.
Q. What happens if I have a tax ID change?
If you are considered in-network with Virginia Premier and do have a tax change, please submit an email and a new updated W-9 form to the Network Development Mailbox.
Q. Can you please provide information regarding billing for non-par providers?
Prior to submitting claims for the first time, providers must submit a current IRS Form W-9. If it has been more than a year since your previous claims submission, please submit an updated W-9. Forms should be submitted to vphp_pdmsupport@virginiapremier.com.
Additional forms are available in the Provider Forms Library on our website.
Q. If I have reached this mailbox in error, can you direct me to the following department for the following?
a. Payspan or portal issues should be directed to your Provider Service Rep for your area. If you should have portal concerns and need technical support, then you can contact 1-877-814-9909.
b. Medical authorizations should be directed to 1-888-251-3063.
c. Claims issues can be directed to 1-800-727-7536, option 4.
d. Credentialing Department issues can be directed to 1-855-813-0385.
Q. Can I submit a Recruitment Form for transportation or Optometry services?
We have recently changed our transportation services to use Southeastrans and you can reach out to Southeastrans to inquire how to join their network.
If you wish to provide vision exam services, please feel free to reach out to our vendor VSP and you can reach out to VSP to inquire how to join their network.
Q: Who should I contact if I suspect fraud?
If you suspect fraud being committed by a Member or Provider, please contact our Program Integrity Office at 800-727-7536 ext. 55173. You can remain anonymous and information will be kept confidential.