Agencies | Governor
Virginia Regulatory Town Hall

Final Text

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Action:
Electronic Claims Submission Requirement
Stage: Final
12VAC30-20-180

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

A. Claims.

 

SERVICE

CLAIM

 

A) Inpatient Hospital

A Bill for Service

 

B) Outpatient Hospital

A Bill for Service

 

C) Rural Health Clinic

A Line Item for Service

 

D) Laboratory and X-Ray

A Line Item of Service

 

E) Skilled Nursing

A Bill for Service

 

F) EPSDT

A Bill for Service

 

G) Family Planning

A Bill for Service or Line Item depending on provider type

 

H) Physician

A Line Item of Service

 

I) Other Medical

A Bill for Service or Line Item depending on provider type

 

J) Home Health

A Bill for Service

 

K) Clinic

A Line for Service Item

 

L) Dental

A Line Item of Service

 

M) Pharmacy

A Line Item of Service

 

N) Intermediate Care

A Bill for Service

 

O) Transportation

A Line Item of Service

 

P) Physical Therapy

A Bill for Service or Line Item depending on provider type

 

Q) Nurse Midwife

A Line Item of Service

 

R) Eyeglasses

A Line Item of Service

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.

2. Good cause may include, but is not limited to, (i) the unavailability of the infrastructure necessary to support electronic claims submission in the provider's geographic region; (ii) the absence of a mechanism for electronic submission for the particular claim type, such as in the case of a temporary detention order; (iii) the provider's inability to transact business through a banking institution capable of EFT; or (iv) financial hardship.