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Provider Appeals Resources

Provider Appeals Resources


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.

Please note: Providers who have received a claim (payment) denial from DMAS may wish to submit a new claim that includes corrections on the claim instead of filing an appeal. If you are unclear about why the claim was denied, DMAS encourages you to contact the Provider Helpline at (800) 552-8627 before deciding whether to file an appeal. If an appeal is filed, it will only address the denial reason(s) set forth on the remittance advice. Filing an appeal does not correct the denial reason(s) nor does an appeal involve reprocessing claims. If you are seeking to correct your claim, do so and resubmit your claim with the claim corrections for payment rather than filing an appeal.

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.

Informal Provider Appeals At-A-Glance Thumbnail
[PDF] Virginia Medicaid Informal Provider Appeals: At-A-Glance

Formal Provider Appeals At-A-Glance Thumbnail
[PDF] Virginia Medicaid Formal Provider Appeals: At-A-Glance


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