Department of Health and Human Services
Centers for Medicare & Medicaid Services
Region III/Division of Medicaid and Children’s Health Operations
801 Market Street, Suite 9400
Philadelphia, Pennsylvania 19107-3134
September 13, 2018
Jennifer S. Lee, M.D., Director
Department of Medical Assistance Services
600 East Broad Street, Suite 1300
Richmond, VA 23219
Re: Virginia Medicaid Provider Enrollment Disaster Relief
Dear Dr. Lee:
The President declared a state of emergency for Virginia and the HHS Secretary declared a Public Health Emergency for Virginia which allows for CMS programmatic waivers based on Section 1135 of the Social Security Act.
Virginia Medicaid currently has the authority to rely upon screening that is performed by other SMAs and/or Medicare. Virginia is not required to create a temporary provisional enrollment for providers who are enrolled with another State Medicaid Agency (SMA) or Medicare.
With respect to providers not already enrolled with another SMA or Medicare, CMS will waive the following screening requirements so the state/territory may provisionally, temporarily, enroll the providers:
- Payment of the application fee - 42 C.F.R 455.460
- Criminal background checks associated with FCBC- 42 C.F.R Section 455.434
- Site visits - 42 C.F.R Section 455.432
- In-state/territory licensure requirements - 42 C.F.R Section 455.412
For those providers located out of state/territory and from which Virginia Medicaid participants seek care, enrollment is not necessary if the following criteria are met:1
- The item or service is furnished by an institutional provider, individual practitioner, or pharmacy at an out-of-state/territory practice location– i.e., located outside the geographical boundaries of the reimbursing state/territory’s Medicaid plan,
- The NPI of the furnishing provider is represented on the claim,
- The furnishing provider is enrolled and in an "approved" status in Medicare or in another state/territory’s Medicaid plan
- The claim represents services furnished, and;
- The claim represents either:
- A single instance of care furnished over a 180 day period, or
- Multiple instances of care furnished to a single participant, over a 180 day period
If the Medicaid participant is enrolled with the Medicaid program from the disaster designated state, the final two criterion will be waived. Therefore, there is no limit to the instances of care furnished or to how many participants in a 180 day period.
In the instance that a certified provider is enrolled in Medicare or with a state/territory’s Medicaid program other than Virginia, Virginia may perform an expedited enrollment, as described above, of an out-of-state/territory facility in order to accommodate participants who were displaced by the disaster.
CMS is granting waiver authority to allow Virginia to enroll providers who are not currently enrolled by meeting the following minimum requirements:
- Must collect minimum data requirements in order to file claims and process, including, but not limited to NPI
- Must collect SSN/EIN/TIN in order to perform the following screening requirements:
- OIG exclusion list
- State/territory licensure – provider must be licensed, and legally authorized, in any state/territory to practice or deliver the services for which they intend to file claims
- Virginia may grant a provisional temporary enrollment that meets the following requirements:
- Must cease approving temporary provisional enrollments no later than the date that the disaster designation is lifted
- Must cease payment to providers who are temporarily enrolled within six months from the date that the disaster designation is lifted, unless a provider has submitted an application that meets all requirements for Medicaid participation and that application was subsequently reviewed and approved by Virginia
- Virginia must allow a retroactive effective date for provisional temporary enrollments that is no earlier than September 12, 2018.
Virginia may temporarily cease revalidation of providers who are located in Virginia or are otherwise directly impacted by the disaster.
If you have any questions or need assistance in regard to this matter, please contact Francis McCullough at either (215) 861-4157 or via email at Francis.McCullough@cms.hhs.gov.
Francis T. McCullough
Associate Regional Administrator