1. Service Authorization Process for MFP Waiver
In this presentation, we will be discussing the service authorization process for MFP waiver.
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2. New Health Coverage for Adults in Virginia
Beginning January 1, 2019, more adults living in Virginia will have access to quality, low-cost health insurance. The new coverage includes hospital stays, doctor visits, preventive care, prescription drugs and much more!
The rules have changed! So, if you applied for Medicaid in the past and were denied, you may soon be eligible. Eligibility is based on income, with a single adult making up to $16,754, or a family of three making up to $28,677, qualifying for coverage.
Interested in learning more?
Check out the below resources or visit for more information and details on eligibility.
Coverage for Adults Brochure (PDF)
Coverage for Adults Flyer (PDF)
FAQs - New Adult Eligibility for Health Coverage (PDF)
Coverage for Adults Poster (PDF)
Beginning January 1, 2019, more adults living in Virginia will have access to quality, low-cost health insurance. The new coverage includes hospital stays, doctor visits, preventive care, prescription drugs and much more!
The rules have changed! So, if you applied for Medicaid in the past and were denied, you may soon be eligible. Eligibility is based on income, with a single adult making up to $16,754, or a family of three making up to $28,677, qualifying for coverage.
Interested in learning more?
Check out the below resources or visit for more information and details on eligibility.
Coverage for Adults Brochure (PDF)
Coverage for Adults Flyer (PDF)
FAQs - New Adult Eligibility for Health Coverage (PDF)
Coverage for Adults Poster (PDF)

3. GAP (GOVERNOR’S ACCESS PLAN)
As part of Medicaid Expansion, On January 1, 2019, Virginia Medicaid will offer new health coverage for adults. Most Governor’s Access Plan (GAP) members will be enrolled automatically in this new program. If the member has any questions about the new health coverage for adults, or if they need to provide notification of a change in where they live, mailing address, phone number, change of income or health insurance coverage, please contact Cover Virginia GAP Processing Unit at
As part of Medicaid Expansion, On January 1, 2019, Virginia Medicaid will offer new health coverage for adults. Most Governor’s Access Plan (GAP) members will be enrolled automatically in this new program.
If the member has any questions about the new health coverage for adults, or if they need to provide notification of a change in where they live, mailing address, phone number, change of income or health insurance coverage, please contact Cover Virginia GAP Processing Unit at

4. Provider Manual/Medicaid Memorandums
DMAS publishes electronic and printable copies of its Provider Manuals and Medicaid Memoranda on the DMAS Web Portal at
This link opens up a page that contains all of the various communications to providers, including Provider Manuals and Medicaid Memoranda.
The Internet is the most efficient means to receive and review current provider information.
DMAS publishes electronic and printable copies of its Provider Manuals and Medicaid Memoranda on the DMAS Web Portal at
This link opens up a page that contains all of the various communications to providers, including Provider Manuals and Medicaid Memoranda.
The Internet is the most efficient means to receive and review current provider information.

5. Resources for Submitting Service Authorization Requests to KEPRO
KEPRO Website DMAS Website portal: For any questions regarding the submission of SRV AUTH requests please contact KEPRO at or
KEPRO Website
DMAS Website portal:
For any questions regarding the submission of SRV AUTH requests please contact KEPRO at or

6. Methods of Submission Service Authorization Requests to KEPRO
All requests for service authorization must be submitted to KEPRO via Atrezzo Provider Portal Connect effective 9/1/2015. The link is:
KEPRO converted to Electronic Process for Submitting Service Authorization Requests – Effective September 1, (DMAS Medicaid Memo dated - 6/15/2015)
All requests for service authorization must be submitted to KEPRO via Atrezzo Provider Portal Connect effective 9/1/2015. The link is:
KEPRO converted to Electronic Process for Submitting Service Authorization Requests – Effective September 1, (DMAS Medicaid Memo dated - 6/15/2015)

7. MFP (Money Follows the Person)‏
MFP SRV AUTH Service Type: 0909
The following services are available under MFP:
H2015 – Transition Coordination
T2028 – Transition Services
S5165 – Environmental Modification
99199 U4 – Environmental Modification Maintenance
T1999 – Assistive Technology
T1999 U5 – Assistive Technology Maintenance
MFP SRV AUTH Service Type: 0909
The following services are available under MFP:
H2015 – Transition Coordination
T2028 – Transition Services
S5165 – Environmental Modification
99199 U4 – Environmental Modification Maintenance
T1999 – Assistive Technology
T1999 U5 – Assistive Technology Maintenance

8. MFP (Money Follows the Person)‏
For MFP enrollment requests, the Transition Coordinator must include documentation stating that the individual meets MFP criteria for enrollment.
Please refer to the applicable Waiver Services Manual, MFP Appendix E for program specific requirements and criteria for available MFP services.
For MFP enrollment requests, the Transition Coordinator must include documentation stating that the individual meets MFP criteria for enrollment.
Please refer to the applicable Waiver Services Manual, MFP Appendix E for program specific requirements and criteria for available MFP services.

9. H2015 (Transition Coordination)
Transition Coordination is only available when the individual is in a Nursing Facility or Long-Stay Hospital at enrollment and will be transitioning to the EDCD Waiver in the community.
Services may be authorized for a maximum of sixty (60) days.
Documentation must include a statement from the provider to certify that the individual meets MFP enrollment criteria.
Transition Coordination is only available when the individual is in a Nursing Facility or Long-Stay Hospital at enrollment and will be transitioning to the EDCD Waiver in the community.
Services may be authorized for a maximum of 60 days.
Documentation must include a statement from the provider to certify that the individual meets MFP enrollment criteria.

10. T2038 (Transition Services)‏
The Transition Coordinator/Case Manager must submit the request for Transition Services.
The patient must be a resident of a Nursing Facility or Long Stay Hospital at the time of request. This service is automatically authorized for a 9 month period, no more, no less.
Transition Services should not be requested until a firm approximate discharge date has been set. This will ensure the dates of service authorized covers a sufficient amount of time post discharge to utilize services.
The Transition Coordinator/Case Manager must submit the request for Transition Services.
The patient must be a resident of a Nursing Facility or Long Stay Hospital at the time of request. This service is automatically authorized for a 9 month period, no more, no less.
Transition Services should not be requested until a firm approximate discharge date has been set. This will ensure the dates of service authorized covers a sufficient amount of time post discharge to utilize services.

11. S5165 (Environmental Modifications) & 99199 U4 (EM Maintenance)
Environmental modifications are physical adaptations to a house, place of residence, primary vehicle or worksite, when the work site modifications exceeds reasonable accommodation requirements of the Americans with Disabilities Act (42 USC § 1201 et. seq.)
Modifications must be necessary to ensure the individuals health and safety or enable functioning with greater independence, and is of direct medical or remedial benefit to the individual.
Modifications cannot be authorized to bring a substandard dwelling up to minimum habitation standards.
This service does not include adaptations or improvements to the home which are of general utility i.e.: carpeting, roof repair.
Environmental modifications are physical adaptations to a house, place of residence, primary vehicle or worksite, when the work site modifications exceeds reasonable accommodation requirements of the Americans with Disabilities Act (42 USC § 1201 et. seq.)
Modifications must be necessary to ensure the individuals health and safety or enable functioning with greater independence, and is of direct medical or remedial benefit to the individual.
Modifications cannot be authorized to bring a substandard dwelling up to minimum habitation standards.
This service does not include adaptations or improvements to the home which are of general utility i.e.: carpeting, roof repair.

12. S5165 (Environmental Modifications) & 99199 U4 (EM Maintenance)
Service is available to individuals who are receiving at least one other qualifying Waiver service: Adult Day Health Care, Personal Care, or Respite Care.
Documentation must include the written description of the item, cost of materials, labor, and must state how it provides direct medical or remedial benefit to the individual.
Items will be covered in the least expensive, most cost effective manner.
Any change in the cost (increase and or decrease) requires supporting documentation, including an itemized list of the cost of materials & labor.
Service is available to individuals who are receiving at least one other qualifying Waiver service: Adult Day Health Care, Personal Care, or Respite Care.
Documentation must include the written description of the item, cost of materials, labor, and must state how it provides direct medical or remedial benefit to the individual.
Items will be covered in the least expensive, most cost effective manner.
Any change in the cost (increase and or decrease) requires supporting documentation, including an itemized list of the cost of materials & labor.

13. S5165 (Environmental Modifications) & 99199 U4 (EM Maintenance)
EM requests may be submitted by Transition Coordinators, DME providers, Personal Care Providers, Service Facilitators, and existing waiver providers that currently perform qualified services. (Adult Day Care, Personal Care, or Respite Care).
EM and activities may include: Installation of ramps and grab bars, widening or doorways, modification of bathroom facilities, or installation of specialized electrical and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the individual, etc...
EM requests may be submitted by Transition Coordinators, DME providers, Personal Care Providers, Service Facilitators, and existing waiver providers that currently perform qualified services. (Adult Day Care, Personal Care, or Respite Care).
EM and activities may include: Installation of ramps and grab bars, widening or doorways, modification of bathroom facilities, or installation of specialized electrical and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the individual, etc...

14. S5165 (Environmental Modifications) & 99199 U4 (EM Maintenance)
Maximum Medicaid funded expenditure is $ per calendar year for all Environmental Modification codes combined.
Cost can not be carried over from one calendar year to another. For example, if the cost of an environmental modification is $ , it can not be split for $ one year and $ the next.
Modification can not be duplicated.
Maximum Medicaid funded expenditure is $ per calendar year for all Environmental Modification codes combined.
Cost can not be carried over from one calendar year to another. For example, if the cost of an environmental modification is $ , it can not be split for $ one year and $ the next.
Modification can not be duplicated.

15. T1999 (Assistive Technology) & T1999 U5 (AT Maintenance)‏
Assistive Technology is defined as the following: specialized medical equipment and supplies, devices, controls, and appliances, not available under the State Plan for Medical Assistance, which enable individuals to increase their abilities to perform activities of daily living, or to perceive, control, or communicate with the environment in which they live, or which are necessary to their proper functioning.
Service is available to individuals who are receiving at least one other qualifying Waiver service: Adult Day Health Care, Personal Care, or Respite Care.
Assistive Technology is defined as the following: specialized medical equipment and supplies, devices, controls, and appliances, not available under the State Plan for Medical Assistance, which enable individuals to increase their abilities to perform activities of daily living, or to perceive, control, or communicate with the environment in which they live, or which are necessary to their proper functioning.
Service is available to individuals who are receiving at least one other qualifying Waiver service: Adult Day Health Care, Personal Care, or Respite Care.

16. T1999 (Assistive Technology) & T1999 U5 (AT Maintenance)‏
All items must be medically necessary.
Devices can not be solely for educational purposes.
AT items can not be duplicated.
AT items can not be rented.
May be multiple items requested within the calendar year, but can not exceed $ for all AT procedure codes combined.
Cost can not be carried over from one calendar year to another For example, if the cost of an Assistive Technology request is $ , it can not be split for $ one year and $ the next.
All items must be medically necessary.
Devices can not be solely for educational purposes.
AT items can not be duplicated.
AT items can not be rented.
May be multiple items requested within the calendar year, but can not exceed $ for all AT procedure codes combined.
Cost can not be carried over from one calendar year to another For example, if the cost of an Assistive Technology request is $ , it can not be split for $ one year and $ the next.

17. T1999 (Assistive Technology) & T1999 U5 (AT Maintenance)‏
Documentation must include the type of professional who recommended the AT and a statement to the need and medical necessity for the purchase.
For children under 21 years of age, if the Assistive Technology request can not be approved under MFP, the request may be submitted directly to DMAS EPSDT Unit for review.
Documentation must include the type of professional who recommended the AT and a statement to the need and medical necessity for the purchase.
For children under 21 years of age, if the Assistive Technology request can not be approved under MFP, the request may be submitted directly to DMAS EPSDT Unit for review.

18. General Information for All Service Authorization Submissions
KEPRO will approve, deny, or pend requests. If there is insufficient medical necessity information to make a final determination, KEPRO will pend the request back to the provider requesting additional information.
Once the case has been received and reviewed, if additional information is needed from the provider, the case is pended for 5 business days to allow the provider time to submit additional documentation to KEPRO for review.
All responses to pended information must be submitted at one time only. The information will be reviewed and processed upon initial receipt. If the information is not received within the time frame requested by KEPRO, the request will automatically be sent to a physician for a final determination.
In the absence of clinical information, the request will be submitted to the supervisor for an administrative review and final determination.
Providers and members are issued appeal rights through the MMIS letter generation process for any adverse determination. Instruction on how to file an appeal is included in the MMIS generated letter.
KEPRO will approve, deny, or pend requests. If there is insufficient medical necessity information to make a final determination, KEPRO will pend the request back to the provider requesting additional information.
Once the case has been received and reviewed, if additional information is needed from the provider, the case is pended for 5 business days to allow the provider time to submit additional documentation to KEPRO for review.
All responses to pended information must be submitted at one time only. The information will be reviewed and processed upon initial receipt. If the information is not received within the time frame requested by KEPRO, the request will automatically be sent to a physician for a final determination.
In the absence of clinical information, the request will be submitted to the supervisor for an administrative review and final determination.
Providers and members are issued appeal rights through the MMIS letter generation process for any adverse determination. Instruction on how to file an appeal is included in the MMIS generated letter.

19. General Information for All Service Authorization Submissions
There are no automatic renewals of service authorizations.
Providers must submit requests for continuation of care needs, with supporting documentation, prior to the expiration of the current authorization.
Providers must verify member eligibility prior to submitting the request.
Authorizations will not be granted for periods of member or provider ineligibility.
Providers must submit a service authorization request under the appropriate service type. Service authorization requests cannot be bundled under one service type if the service types are different.
There are no automatic renewals of service authorizations.
Providers must submit requests for continuation of care needs, with supporting documentation, prior to the expiration of the current authorization.
Providers must verify member eligibility prior to submitting the request.
Authorizations will not be granted for periods of member or provider ineligibility.
Providers must submit a service authorization request under the appropriate service type. Service authorization requests cannot be bundled under one service type if the service types are different.

20. Out-of-State Providers
Out-of-State providers must be enrolled with Virginia Medicaid in order to submit a request for Out-of-State services to the Contractor. If the provider is not enrolled as a participating provider with Virginia Medicaid, the provider is still encouraged to submit the request to the Contractor, as timeliness of the request will be considered in the review process starting November 1, These providers will not have a NPI number but may submit a request to the Contractor.
The Contractor will advise Out-of-State providers that they may enroll with Virginia Medicaid by going to:
(At the toolbar at the top of the page, click on Provider Services and then Provider Enrollment in the drop down box.  It may take up to 10 business days to become a Virginia participating provider.)
Out-of-State Providers:
Out-of-State providers must be enrolled with Virginia Medicaid in order to submit a request for Out-of-State services to the Contractor. If the provider is not enrolled as a participating provider with Virginia Medicaid, the provider is still encouraged to submit the request to the Contractor, as timeliness of the request will be considered in the review process starting November 1, These providers will not have a NPI number but may submit a request to the Contractor.
The Contractor will advise Out-of-State providers that they may enroll with Virginia Medicaid by going to:
(At the toolbar at the top of the page, click on Provider Services and then Provider Enrollment in the drop down box.  It may take up to 10 business days to become a Virginia participating provider.)

21. VIRGINIA MEDICAID WEB PORTAL
DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, check status, service limits, service authorizations, and electronic copies of remittance advices. 
Providers must register through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going to:  
DMAS offers a web-based Internet option to access information regarding Medicaid or FAMIS member eligibility, claims status, check status, service limits, service authorizations, and electronic copies of remittance advices. 
Providers must register through the Virginia Medicaid Web Portal in order to access this information. The Virginia Medicaid Web Portal can be accessed by going to:  

22. DMAS Helpline Information AND/OR Resources
The “HELPLINE” is available to answer questions Monday through Friday from 8:00 a.m. to 5:00 p.m., except on holidays. KEPRO Website DMAS web portal For any questions regarding the submission of Service Authorization requests, please contact KEPRO at or For claims or general provider questions, please contact the DMAS Provider or
The “HELPLINE” is available to answer questions Monday through Friday from 8:00 a.m. to 5:00 p.m., except on holidays.
KEPRO Website
DMAS web portal
For any questions regarding the submission of Service Authorization requests, please contact KEPRO at or
For claims or general provider questions, please contact the DMAS Provider or

23. THANK YOU
THANK YOU!
Thank you for reviewing this presentation.