We know that you are busy, and having access to the latest Virginia Premier tools and information is critical in today’s fast paced healthcare environment. So Virginia Premier decided to create an area dedicated to providing quick and easy access to the latest Virginia Premier provider communications and tools.
The Provider Manual is one of the many tools that Virginia Premier has available to make doing business with us easier. The Provider Manuals contain Virginia Premier’s policies and processes on topics such as Member Benefits and Covered Services, Claims and Electronic Payments, Medical Management, Pharmacy Guidelines and much more.
- Newborn Notification Process
- Virginia Premier Medicaid Provider Manual
- Provider Claim Reconsideration Guide
- Provider Manual Supplement – This Provider Manual Supplement will be effective July 1st, 2023.
2022
2021
2020
2019
2018
2017
2016
Below, you can find a comprehensive listing of all provider notifications and changes that have been communicated to our network providers.
2023
- Provider Notice-Encourage Your Patients to Renew Their Medicaid Coverage
- Provider Notice-ASAM Skill Building Training Dates
- Provider Notice- Authorization Requests for Personal Care Services
- Provider Notice-Virginia Premier Appointment Standards
- 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
2022
- 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
- Provider Notice-Virginia Medicaid Regulatory Updates to Provider Agreements
- Provider Notice-Virginia Premier Announces Changes to Claims Processing Schedule
- Provider Notice-Announcing Changes to the Credentialing Process For Crisis Services
- Provider Notice-Zelis to Provide Claims Review
- Provider Notice-COVID-19 Support Payments
- Provider Notice-Extension of Medicaid Coverage for New Moms
- Provider Notice-Virginia Premier Partnering With Cotiviti To Complete Claims Audits
- Provider Notice-Partnership with DarioHealth Supports Members with Type 2 Diabetes
- Provider Notice-Changes to Hearing Benefit for Pediatric Patients Take Effect October 1
- Provider Notice-PRSS Portal Update Enrollment Outreach Begins Soon For MCO Providers
- Provider Notice-Connecting Members with Support After a Hospital Stay
- Provider Notice-Registering with Virginia Premier for Secured Faxes
- Provider Notice-Connecting Your Patients With Support
- Provider Notice-Virginia Premier Launching Doula Benefit for Pregnant Members
- Provider Notice-DMAS Shares Details on MES Implementation
- Provider Notice-New Fax Line for Service Authorization Requests
- Provider Notice-Provider Education Medicare Stars Measures
- Provider Notice-Other Health Verification Via the Provider Portal
- Provider Notice-CMS Announces Fee-for-service Payment Adjustments
- Provider Notice-Standard Authorization Requirements Resume March 1
- Provider Notice-Hearing Aid Benefit for Medicaid Members
2021
- Provider Notice-Project BRAVO Phase 2 Implementation
- Provider Notice-Infant Enrollment Notification
- Provider Notice-OB Global Payment: Provider Billing Guidelines
- Provider Notice-Expanded Adult Dental Benefits
- Provider Notice-Payment Policy Changes
- Provider Notice-Remit and 835 File Process
- Provider Notice-Payment Policy Changes for Modifier 25
- Provider Notice-SET Transportation Scheduling
- Provider Notice-CMHRS Overlapping Services
- Provider Notice-COVID-19 Update
2020
- Provider Notice-CMHRS Overlapping Services
- Provider Notice-Nursing Facility Care
- Provider Notice-Crisis Stabilization Registration
- Provider Notice-Case Management Care Coordination Billing
- Provider Notice-Audit Resumption
- Provider Notice-COVID-19 Payment Relief
- Provider Notice-Provider Guidance MHSS
- Provider Notice-Hospital Reimbursement
- Provider Notice-Service Facilitation Limits and Authorizations
- Provider Notice-March 30 Coronavirus (COVID-19) Update – Service Authorizations
- Provider Notice-March 16 Coronavirus (COVID-19) Update
- Provider Notice-List of CES Edits
2019
- Provider Notice-Kaiser Communication
- Provider Notice-Online Claim Reconsiderations
- Provider Notice-New Provider Portal and Prior Authorization List Tools Available
- Provider Notice-LTSS Screening Requirements for Nursing Facilities
- Provider Notice-Best Practices for Submitting Claims with Authorizations
- Provider Notice-Hospice Room and Board Reimbursement
- Provider Notice-Operational Excellence
- Provider Notice-LTSS Screening Requirements and Associated Claims Reimbursement
- Provider Notice-Electronic Claim Submission
- Provider Notice-Readmission Payment Policy
- Provider Notice-Billing Guidelines Policy
- Provider Notice-Best Practices for Submitting Claims with Authorizations
- Provider Notice-List of HCI Edits
- Provider Notice-Vendor Transition
- Provider Update-Virginia Premier Behavioral Health Authorization Requests
- Provider Update-CMHRS and ARTS Claims Processing
- Provider Communication Letter-No Authorization Required for Early Intervention Services
- Provider Notice-Opioid Drug Management Program
- Sample Member IDs
- Virginia Premier Universal Payer ID
- Provider Information
- Provider Call Center- How to Contact Us
- Utilization Review Process
- Provider Notice – Important Information Concerning Electronic Claims Submission
2018
- Provider Communication Letter_ Virginia Premiers Electronic Claims Submission
- Provider Communication Letter Medallion 4.0 Claims Submission PO Box Update
- Virginia Premier Elite Plus (CCC Plus/MLTSS) Provider Resource Tool
- Provider Update – Provider Corrected Claim Update
- Provider Update – CCC Plus Coordination of Benefits (COBA)
- Provider Update – EFT ERA Changes
- Provider Update – EDI Errors
- Critical Incident Reporting form
- Provider Notice-SSRNI
- Provider Notice – Continuity of Care Update
- Provider Notice – New UM Process
2017
- ARTS postcard
- Provider Notice – Incontinent _Supplies
- Provider Notice – MM New Fax Line
- Mandatory Provider Training for Critical Care and Model of Care Notice
- Provider Notice – Behavioral Health and Arts Auth Notice
- Provider Notice – Early Intervention Notice
- Provider Notice – Provider Payment Date Change
- Provider Notice – Coordination of Benefits (COBA)
- Provider Notice – NDC Billing Requirement
Interested in the opportunity to interact with your local Provider Services team and other providers in your area? Then attend one of Virginia Premier’s quarterly Provider Education Meetings that are held throughout our various service areas. These meetings are intended to give providers and their staff the opportunity to exchange ideas and suggestions with Virginia Premier staff while also receiving the latest news and updates. To attend, please call the Provider Relations Call Center at 804-968-1529 (M-F 8am to 6pm) or contact a regional contact below.
Central
- Quarter 1
- 03/21/2023
- Quarter 2
- 05/16/2023
South West Virginia
- Quarter 1
- 03/23/2023
- Quarter 2
- 05/17/2023
Central West Virginia
- Quarter 1
- 03/21/2023
- Quarter 2
- 05/16/2023
Tidewater
- Quarter 1
- 03/09/2023
- Quarter 2
- 05/23/2023
Roanoke
- Quarter 1
- 03/09/2023
- Quarter 2
- 05/18/2023
Northern Virginia
- Quarter 1
- 03/09/2023
- Quarter 2
- 05/18/2023
Central Virginia
- Michael Terrell at 804-613-5065 or email: Michael.Terrell@virginiapremier.com
- Tina Carter at 804-613-4969 or email: Ernestine.Carter@virginiapremier.com
Roanoke
- Keyera Pettiford 804-613-4890 ext. 22415 or email: kspettif@sentara.com
- Ebony Franklin at 804-613-5070 ext. 20140 or email: Ebony.Franklin@virginiapremier.com
- Miriam Webb at 804-613-6613 or email: Miriam.Webb@virginiapremier.com
- Earl Dooley at 804-613-5042 ext. 20117 or email: Earl.Dooley@virginiapremier.com
- Katina Keeling at 804-613-4890 ext. 22299 or email: Katina.Keeling@virginiapremier.com
Tidewater
- Paige McPeak at 804-613-6071 or email: Paige.McPeak@virginiapremier.com
- Sherri Clark at 804-613-4988 or email: Sherri.Clarke@virginiapremier.com
- Dominic Pearsall at 804-660-8614 or email: Dominic.Pearsall@virginiapremier.com
- Scottie Mitchem at 757-687-6428 or email: Scottie.Mitchem@virginiapremier.com
South West Virginia
- Danielle Shaw at 804-613-6431 or email: Danielle.Shaw@virginiapremier.com
- Kim Orr at 804-793-8403 or email: Kimberly.Orr@virginiapermier.com
- Tammy McIntosh at 804-613-6047 or email: Tamara.McIntosh@virginiapremier.com
Northern Virginia
- Alijah Evans at 804-613-5061 or email: Alijah.Evans@virginiapremier.com
Central West Virginia
-
Brittany Baxter at 804-660-8619 or email: Brittany.Baxter@virginiapremier.com
- CMS Fraud, Waste and Abuse Prevention Training
- Cultural Competency Training **
- **Once training is completed, please fill out and submit the Cultural Competency Attestation Form.
- Critical Incident Reporting Training
- Trauma-Informed Care Course
References
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 accompanied by a certificate of medical necessity form (CMN) form for documentation purposes. However, the Utilization Management Department will accept the initial request written by the provider to ensure timely service for the member.
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, 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.
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 Manager at 800-727-7536 ext. 55104. You can remain anonymous and information will be kept confidential.