Virginia VA

Virginia DMAS (Cardinal Care) expresses prior authorization as "Service Authorization" (SrvAuth/SA). There is NO single PA-criteria list. Criteria live PER-SERVICE in DMAS Provider Manuals, each of which contains a "Chapter 7 / Appendix D: Service Authorization Information" chapter plus a "Chapter 6/V: Utilization Review and Control" chapter that define what requires SA and the review process. Operationally: FFS SA is handled by contractor Acentra Health (formerly Kepro) via the Atrezzo Next Generation (ANG) portal; Cardinal Care managed-care SA goes to one of 6 MCOs; pharmacy, dental, transportation, and ID/DD waivers are carved out to separate contractors. Effective Nov 1 2023 all FFS providers submit SA to Acentra. The DMAS SA hub moved to the new Atrezzo SA site at vamedicaid.dmas.virginia.gov/sa (Forms, Reference Info, Provider Checklists, FAQs). Authoritative artifacts gathered: per-service SA chapter (Rehab Manual Appendix D + Chapter VI as exemplar), Atrezzo Provider Portal UM User Guide, waiver enrollment/SA chart, BH Service Authorization Registration Grid (the closest thing to a 'what needs SA' code grid), ARTS + BH Service Types, and two SA provider checklists (ACT, MHSS). Authority = DMAS (sets criteria via manuals/memos) + Acentra (FFS UM operator) + the 6 Cardinal Care MCOs (MC UM). No bot-wall; all PDFs/XLSX fetched via in-page chromium fetch. CMS-0057-F interoperability/PA rule implementation is actively tracked on the SA site.

Last award: 2024-12-30. Next due: approx 2030 (RFP for next cycle if renewals not exercised). Contracts extended through: None.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How VA requires PA Virginia Medicaid's prior authorization (PA) requirements are detailed in various provider manuals and service-specific documents. The primary document governing PA is the Virginia Medicaid Provider Manual, which outlines medical necessity criteria, step-therapy protocols, and required documentation for services and drugs. Each service covered under Medicaid has its own specific PA criteria outlined in the respective chapters of the Provider Manual, particularly Chapter 7 / Appendix D: Service Authorization Information. For example, the Outpatient Rehabilitation Services manual specifies that CPT codes 97530-97534 require medical necessity and patient history documentation. The document also notes that step therapy is not applicable for these services. Similarly, the Mental Health Skill-Building Services (MHSS) checklist requires clinical necessity due to serious mental illness with functional impairments and documentation of diagnosis, prior hospitalization or stabilization services, and medication history within 12 months. The Behavioral Health Service Types document specifies that certain services like Outpatient Psych EBH Community Stabilization (S9482) require step therapy and continued authorization. In contrast, other services such as Outpatient Psych EBH 23-Hour Crisis Stabilization (S9485) do not require PA. ## 2. How VA publishes and reports PA Virginia Medicaid publishes its PA requirements through various channels, including provider manuals and service-specific documents. The primary source for PA criteria is the Virginia Medicaid Provider Manual, which includes Chapter 7 / Appendix D: Service Authorization Information for each service covered under Medicaid. These documents are available on the Virginia Department of Medical Assistance Services (DMAS) website. For example, the Outpatient Rehabilitation Services manual was revised on September 16, 2025, and is effective for dates of service on or after December 1, 2018. The Mental Health Skill-Building Services checklist was updated on October 20, 2023. VA Medicaid also utilizes electronic portals for submitting PA requests. Providers can use the Acentra/Atrezzo portal to submit prior authorization requests for fee-for-service (FFS) services. The Atrezzo Provider Portal User Guide provides instructions on how to navigate and use this portal effectively. For managed care organizations (MCOs), providers should refer to their respective MCO guidelines. ## 3. VA's CMS-0057-F and PA-reform compliance posture Virginia Medicaid has not explicitly detailed its compliance with CMS-0057-F in the source documents. However, based on the available documents, Virginia has implemented several PA-process features consistent with reform aims. For instance, the Outpatient Rehabilitation Services manual specifies that step therapy is not applicable for CPT codes 97530-97534, which aligns with reforms aimed at reducing administrative burden. The Mental Health Skill-Building Services checklist requires clinical necessity documentation and specific criteria, ensuring that services are only authorized when medically necessary. Virginia Medicaid also uses electronic portals like Acentra/Atrezzo for submitting PA requests, which can improve efficiency and reduce processing times. **WISeR is not applicable to VA** — the CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model applies only to AZ, NJ, OH, OK, TX, and WA. ## 4. How VA runs its own program Virginia Medicaid operates under a mixed model that includes fee-for-service (FFS) and managed care organizations (MCOs). The state has six Cardinal Care MCOs, which are responsible for managing Medicaid services for certain populations. For FFS services, Virginia uses Acentra/Atrezzo as the portal for submitting prior authorization requests. The Foster Care Specialty Plan (FCSP) is a carve-out program that provides specialized behavioral health services to foster care youth under age 21. Prior authorization for these services can be requested via electronic request to Acentra Health or through the designated MCO Health Plan. Virginia Medicaid's PA process is decentralized, with criteria and procedures outlined in various provider manuals and service-specific documents. The DMAS Provider Manual serves as the primary source of information for FFS services, while each MCO may have its own guidelines for managed care services. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Decentralized PA Criteria**: Each service covered under Medicaid has its own specific PA criteria outlined in the respective chapters of the Provider Manual. - **Electronic Portals**: Virginia uses electronic portals like Acentra/Atrezzo for submitting prior authorization requests, which can improve efficiency and reduce processing times. - **Service-Specific Documentation**: Providers are required to submit detailed documentation supporting medical necessity for each service. ### What's Missing/Uncertain: - **CMS-0057-F Compliance**: There is no explicit mention of Virginia's compliance with CMS-0057-F or any formal reporting on its PA reforms. - **Pharmacy Carve-Out Details**: The document summaries do not provide specific details about the pharmacy carve-out direction in Virginia. - **Gold Card Law**: The status and specifics of any Virginia gold card law are unspecified. - **Effective Dates**: Many documents do not specify effective dates, making it challenging to track changes over time. These gaps highlight areas where additional information would be beneficial for a more comprehensive understanding of Virginia Medicaid's PA process.