Clarification on Process for Admitting Medicaid MCO Beneficiaries

The Department of Medical Assistance Services (DMAS) has notified us that they have been receiving numerous phone calls related to admissions of individuals with Medicaid Managed Care Organizations (MCO) who are seeking nursing facility placement.  The introduction of Medicaid managed care for populations requiring primary and acute care in the Roanoke area is likely driving most of the calls from nursing facilities.  The process for admitting Medicaid MCO individuals into the nursing facility is the same for both MCO and non MCO individuals.  Once the individual is admitted into the nursing facility, the facility must submit the PIRS (Patient Intensity Rating System, DMAS-80) form within 30 days of admission or notification of financial Medicaid eligibility to the Long Term Care Division at DMAS.  This information can be found in the Virginia Medicaid Nursing Facility Manual Chapter VI. 

The nursing facility admission level of care is then entered in the DMAS computer system, within five working days as required by DMAS policy.  Once the nursing facility level of care is entered in the system, this prompts the immediate disenrollment of the individual from the Medicaid MCO and establishes the beneficiary for fee-for-service coverage. 

The nursing facility must submit the DMAS-225 to the local Department of Social Services to show the admission date, request Medicaid eligibility status, the Medicaid recipient I.D., and the patient pay amount.  The Medicaid Eligibility Policy Manual, M1320.200B, states "the time standard for evaluating a reported change is 30 days from the date the worker receives notice of a change in circumstances or a medical or dental expense submitted by the individual".  There is no DMAS requirement that prohibits the nursing facility from submitting the DMAS 80 prior to the patient pay determination; however, a nursing facility may not bill DMAS for services rendered prior to verification of patient pay amounts.

When the process outlined above is not followed, there will be a delay in the conversion from MCO to fee for service for the individual, which will likely lead to Medicaid coverage service issues.  In summary, the conversion process relies on the initiation of the admitting nursing facilities to submit the DMAS-225 to the local social service agencies and to submit the DMAS-80 to DMAS.  Once DMAS receives the DMAS-80 from the admitting nursing facility the conversion to fee for service takes place.  This conversion will not take place prior to receiving the DMAS-80.

Please contact the DMAS Long Term Care Division at 804.225.4222 with any questions.