Coronavirus (COVID-19) Provider Appeals

The following changes have been made in response to the COVID-19 pandemic.

Medicaid:

Provider Appeals Pursuant to the Governor’s Declaration of a State of Emergency issued on March 12, 2020 (Executive Order 51), the DMAS Director is authorized to waive state requirements and regulations. DMAS is exercising its authority for deadlines that govern provider appeals that are specified in the Code of Virginia and DMAS’ provider appeal regulations.  The provider appeals process will follow its current process with the below changes:
  • COVID-19 Hardship Exemption
    • Providers affected by the COVID-19 emergency can request a hardship exemption to the normal deadline to file an appeal. The provider’s request for an informal appeal or formal appeal must state an exemption is being requested and the reason for the exemption.
    • Virginia Premier will accept provider appeals as timely filed if a hardship is indicated on the appeal request.
  • Time Limits
    • Appeal deadlines have been extended to the period of the declaration of emergency after the appeal has been filed; e.g. if the declaration of emergency lasts 50 days, the appeal deadline is extended 50 days. This applies to the following formal and informal appeal deadlines.
  • All informal fact-finding conferences and formal hearings will be conducted by telephone during the period of emergency.

Formal Appeals

  • Hearing date
  • Post-hearing briefs
  • Recommended decision
  • Exceptions
  • Final agency decision

Informal Appeals

  • Case summary
  • Informal-fact-finding conference (IFFC)
  • Document submission after IFFC
  • Informal appeal decision

Medicare:

There will be no time limits for filing an appeal during the Virginia State of Emergency. Similarly, if an appeal is missing information, we will continue to process it as a complete appeal and there will be no time limit for you to provide the missing information to us. However, if the request includes an incomplete Appointment of Representative form, then we will only be able to communicate information about the appeal with the member.

Individual and Family:

There will be no time limits for filing an appeal during the Virginia State of Emergency. Similarly, if an appeal is missing information, we will continue to process it as a complete appeal and there will be no time limit for you to provide the missing information to us. However, if the request includes an incomplete Appointment of Representative form, then we will only be able to communicate information about the appeal with the member. 

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