Title of Regulation: 12VAC30-20. Administration of Medical Assistance Services (amending 12VAC30-20-180).

Statutory Authority: § 32.1-325 of the Code of Virginia.

Effective Dates: September 4, 2012, through September 3, 2013.

Agency Contact: Tom Edicola, Director, Program Operations Division, Department of Medical Assistance Services, 600 East Broad Street, Richmond, VA 23219, telephone (804) 786-8098, FAX (804) 786-1680, or email tom.edicola@dmas.virginia.gov.

Preamble:

The department is promulgating this emergency regulation to comply with Chapter 890, Item 300 H of the 2011 Acts of Assembly, which requires the department to implement a mandatory electronic claims submission process, including the development of an exclusion process for providers who cannot submit claims electronically.

Approximately 84% of all Medicaid claims are currently filed electronically with the department. A survey of participating Medicaid providers who submit claims on paper was performed to better understand why claims are filed on paper when electronic filing is available and to understand any barriers that may exist to filing electronically. The survey found that the main barriers to electronic filing were cost and inadequate technology. However, a majority of providers indicated that they transact business electronically with commercial carriers and would welcome the change if these barriers could be addressed for Medicaid.

The department has implemented a Web-based Direct Data Entry solution that allows for electronic claim submission at no cost to the provider and at a lower cost for Virginia to process these claims. Language mandating the participation of providers via electronic funds transfer and electronic claims submissions is part of an overall strategy to simplify the claims submission process, increase processing efficiency, lower costs for both the Commonwealth and the Virginia Medicaid provider community, and support collaboration and consistency in business practices with other commercial carriers and Medicare. In this regulation, the department has identified the common reasons for which providers may be unable to submit claims electronically and anticipates that additional reasons will be identified during the standard regulatory process.

12VAC30-20-180. Definition of a claim by service.

A. Claims:

B. All providers that enroll with Medicaid on or after October 1, 2011, shall submit electronically all claims for covered services they render in the fee-for-service program under the State Plans for Title XIX and XXI of the Social Security Act, and any waivers thereof and enroll to receive Electronic Funds Transfer (EFT) for payment of those services. All other providers shall comply with this electronic submission requirement by July 1, 2012.

1. Any provider who cannot comply with this electronic claims submission or EFT requirement may request an exception from DMAS for good cause shown. Good cause may include, but is not limited to, the unavailability of the infrastructure necessary to support electronic claims submission in the provider's geographic region; there is no mechanism for electronic submission for the particular claim type, such as in the case of a Temporary Detention Order (TDO); the provider is unable to transact business through a banking institution capable of EFT; or for financial hardship.