Virginia MedicaidOverview
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.
How to Request an Appeal
Pursuant to a mandate from the Virginia General Assembly, regulations requiring provider appeals to only be filed and processed online became effective November 5, 2026. Therefore, providers must utilize the Appeals Information Management System (“AIMS”).
Complete the following steps to file an appeal in AIMS:
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Register for AIMS. In order to file an appeal, an authorized staff member or contractor of the provider must first register for AIMS. The registration request will be reviewed by DMAS to make sure the individual is permitted to view protected health information. Allow 2-3 business days for the registration request to be reviewed.
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File the Appeal in AIMS. If the registration request is approved, the provider’s authorized staff member or contractor can then log into AIMS to submit a new appeal request. It is helpful to upload an appeal letter to outline what is being contested. Include the member’s name, date(s) of service, and claim or authorization number. Also upload a copy of the denial notice being appealed. Additionally, if there are other documents to support the appeal, upload them to AIMS. Due to file size restrictions, anything 1GB or larger must be broken down into multiple smaller files.
The appeal request must complete transmission in AIMS by 5:00pm on the deadline date.
Exceptions to the AIMS filing requirement can be requested, but are only available for limited circumstances. Those include: (1) The infrastructure necessary to support electronic submission is not available in the provider's geographic region; (2) The disability of all members of a provider's staff prevents their use of AIMS; and (3) The provider cannot transmit documents through AIMS due to unusual or unavoidable circumstances. Exceptions must be requested in writing in advance of the appeal filing deadline. The request must have a subject of “Exception Request for Portal Filing.” For emails (appeals@dmas.virginia.gov), this must be in the subject line. For delivered requests, this must be underneath the address block (DMAS, Attn: Appeals Division, 600 East Broad Street, Richmond, VA 23219) on the cover letter. If an exception is granted by DMAS, the provider can file their appeal via mail/delivery or email.
Refer to Chapter II of the DMAS Provider Manuals for additional appeal request requirements. The Appeals Division will only process provider appeal requests that meet these requirements.
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.
[PDF] Virginia Medicaid Informal Provider Appeals: At-A-Glance
[PDF] Virginia Medicaid Formal Provider Appeals: At-A-Glance
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