Provider Tools and Resources | Virginia Premier

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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.

Network Providers

Transportation Providers

Update Your Information

Need to update Virginia Premier about changes to your provider information? Let us know about changes >

Contact Provider Relations

Call our Provider Inquiry Line at 804-968-1529, 8:00 am to 6:00 pm, Monday through Friday.

Portal Login

System Upgrade 6/5/20 – 6/9/20

Due to a system upgrade, our claims management platform will not be available on Friday, June 5th from 12pm to close of business. This will not impact our provider portal and we are available to assist with general questions.

Due to a system upgrade, our member and provider portals will be unavailable on Monday, June 8th from 6pm until 8am, Tuesday, June 9th.

Effective 9/30/19

Providers will be required to review authorization status by utilizing the authorization inquiry functionality in the Provider Portal selection, titled “Medicaid, CCC Plus, Medicare Advantage, DSNP, VCC” (Orange Box). For additional questions please contact the Provider Service Line 1(804) 968-1529

Terms & Conditions

By logging in to this portal, I affirm that I have read, understand and agree to abide by the following terms and conditions:

I certify I am a health care provider, an employee of a health care provider, a business associate of a health care provider, or an employee of a business associate, and the purpose of my access to any Virginia Premier System is related to the provision or payment of health care services.

With respect to all information viewed or obtained from this site, I agree to comply with all applicable federal and state laws regarding the confidentiality and integrity of health and medical records. This includes full compliance with the Health Insurance Portability and Accountability Act of 1996 (‘HIPAA’), the HITECH Act, and the Virginia Health Records Privacy Act, and applicable regulations to these laws.

I agree to keep confidential all information related to Virginia Premier System business, including, but not limited to, quality and risk management activities as well as other confidential or personal information concerning the medical, personal, or business affairs of Virginia Premier System and its members.

I agree to notify Virginia Premier System immediately in the event that my network access has been compromised in any way and in the event of unauthorized use or disclosure of any information obtained from the Virginia Premier System network.

New Users

Need to register for a new account? Click here.

In order to register for an account, if you would like access to all group NPIs/APIs under a single Tax ID, please enter your Tax ID only. If you would like access to a specific group NPI/API instead, please enter it in the field provided.

For expedited registration, please provide a Claim number and the Total Billed Charges on the claim when creating your account.

You will receive an email within 3-5 business days with your username and temporary password.

Need Help?

Please call Technical Support for help with Virginia Premier’s Provider Portal at 1-877-814-9909 or email connect@healthtrio.com.

PaySpan EFT Services

Virginia Premier is offering EFT services through PaySpan.

Please click here to sign-up

If you have questions or need help please, contact our Provider Services department at vphpnetdev@virginiapremier.com or by calling 804-968-1529.

Provider Resources

Provider Manual

This comprehensive resource describes how we will work together as you care for your patients’ health.

Medicaid | Medicare
Individual and Family

HEDIS Quality Toolkit

Virginia Premier has helpful HEDIS-related provider tools that provide you with details about each measure.

Prior Authorization List Search

Some drugs and/or procedures require prior authorization before Virginia Premier will cover the cost.

Newsletters

Access the latest health care news and updates from Virginia Premier.

W9 Submission

Please send your completed W9 to vphp_pdmsupport@virginiapremier.com

Provider Inquiry Line

Call our Provider Inquiry Line at 804-968-1529 8:00 am to 6:00 pm, Mon-Fri.

Recent Provider Notices

More Medicaid provider notices >
More Medicare provider notices >

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.

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

Medallion Members

Commonly Used Coverage Determination Forms

Drug/Disease Specific Specialty Drug Order Forms

General Specialty Drug Order Forms

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 180 days as allowed per NCQA guidelines. However, in most cases the process can be completed in as little as 90 days.

Q. Does Virginia Premier participate with CAQH?

Yes we do. Virginia Premier highly encourages all providers to utilize CAQH, www.caqh.org 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 the form, fill it in and fax it 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.

Providers