Provider not eligible denials — Action required

Previously, HealthKeepers, Inc. notified providers of impending regulatory provider requirements. The Federal 21st Century Cures Act requires all providers including billing, rendering, attending, ordering, and referring providers who serve Medicaid members through managed care organization (MCO) networks to enroll directly with the Virginia Department of Medical Assistance Services (DMAS) through the Medicaid Provider Services Solution (PRSS) enrollment website.

Beginning July 1, 2023, DMAS has required HealthKeepers, Inc. to implement claims denials for the billing, rendering, and attending provider when the provider is not enrolled with DMAS. These denials will not generate payment until the provider's enrollment status is updated with DMAS.

The following line/claim explanation denial codes apply:

Soft edits for the ordering and referring provider are configured as an Explanation of Benefits (EOB) description at either the claim or line level. These edits will allow the claim to reimburse according to normal processing guidelines. This is an informational only edit, notifying the provider that the DMAS enrollment criteria are not met. DMAS states that these edits will become hard denials at a future date. Providers are encouraged to address these providers' enrollment status immediately.

Providers receiving these denials must enroll with Virginia Medicaid using the PRSS enrollment website to complete this mandatory process to receive future payments. Providers will find the enrollment application by going to the PRSS enrollment website at https://virginia.hppcloud.com. Select Menu in the top left corner, select Provider Enrollment, and then choose New Enrollment. Should you have questions during the Virginia Medicaid enrollment process, contact Gainwell* at 888-829-5373.

Submit your application to Gainwell Provider Enrollment immediately through the PRSS enrollment website. You may be asked to provide evidence of your submission, so we encourage you to keep a copy of your application.

If you have additional questions regarding how or why you were identified as a provider who needs to enroll in Virginia Medicaid, call the PRSS Provider Enrollment Helpline at 804-270-5105 or 888-829-5373. You can also email Provider Enrollment at vamedicaidproviderenrollment@gainwelltechnologies.com.

Thank you for your prompt attention and cooperation.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.