Providers, individuals, or entities that have a contract with DMAS to provide services may appeal any DMAS action subject to appeal under the applicable laws and regulations, including issues related to reimbursement for covered services, DMAS's interpretation and application of payment methodologies and provider enrollment. As part of the appeal process, an impartial representative will conduct a review to determine whether the action proposed or taken was correct. The end result of the appeal is a written decision. Formal appeal decisions by the DMAS Director may be appealed to court for review of the record.
Resubmitted claims will be processed as quickly as possible (usually within 30-60 days or sooner). If another denial occurs, that remittance advice will carry new appeal rights to DMAS.
Provider Appeal Resources
Provider Appeal Forms
Provider Appeal Regulations
Code of Virginia - Section 2.2-4000 et seq. (Administrative Process Act)
Code of Virginia - Section 32.1-325.1 (Specific to DMAS Appeals)
Virginia Administrative Code - 12VAC30-20-500 through 570
Rules of the Supreme Court of Virginia Code of Virginia Part Two A - Appeals Pursuant to the Administrative Process Act