Virginia Workflow

Overview

(As always, private pay is generally self-regulating within the confines of state law and regulatory processes. This article focuses on Medicaid billing in the state of Virginia.)

In the state of Virginia, there are some unique billing processes. This is because while the MCO Anthem requires providers to use Mobile Caregiver Plus (NetSmart, formerly Tellus) as their clearinghouse, there are options for other MCOs. This means you can use NetSmart for other MCOs, or use another clearinghouse (such as Availity) for the other 5 MCOs. For straight (non-MCO) Medicaid, Conduent is free, but Availity or NetSmart can process these visits if you are on the paid plan. For Ankota users, that means in addition to our regular EVV services which we provide, we also deliver visit data to the desired clearinghouse to ensure your state's requirements are met. This article will help guide you through this process.

This article covers:

Critical Pathway

Set-up and Testing

Pre-Billing

Billing Management for Medicaid Visits

Corrected Claims

Remittance Advice Management (835s)

Further Details

Critical Pathway

For a simple overview of key admin system maintenance, see this overview with linked steps: Virginia Critical Pathway.pdf

Set-up and Testing

Note that caregivers are required to have 1 profile in Ankota. (Admins can have both caregiver and admin profiles in order to access different levels of permissions.) Caregivers must be paid in a single payroll per Virginia standards.

NetSmart

Ankota users in Virginia must register for EVV so that their Anthem claims can be billed. (Ankota will deliver visit data to NetSmart/Mobile Caregiver Plus.) This registration will ensure NetSmart will accept their data and give providers access to the NetSmart log-in. Internally, Ankota users are automatically set up for delivery of EVV visit data to the state as part of implementation. Testing is not necessary.

Alternately, send an email to dl_evv_sales@ntst.com and provide them with the following information:

Agency Name
Contact Email
Phone Number
Payer – Anthem
Provider Name
Provider EIN
Provider NPI
Medicaid ID#

They will, in turn, will send you a confirmation within 24-48 hours. Should you not receive anything, please reach out to them at 833-4-TELLUS and check status.

NOTE: If you wish to upgrade to a paid NetSmart account (for non-Anthem payers in Virginia; Anthem is free) so that all your billing is through one clearinghouse, you can do so, but please note that the cost of adding payers has increased. As of the last update in 2022, it was $400/payer for set-up plus $15 per month.

Availity

Ankota users in Virginia must register for Availity if they wish to use them for non-Anthem MCOs. Ankota will set up Availity during implementation upon request. Testing is not necessary. A paid account is needed for some MCOs and for straight Medicaid. Be sure to complete the full set-up if you wish to have automated file transfer, including providing Ankota with your Availity FTP user name and password.

Conduent

Ankota users in Virginia must register with Conduent if they wish to use them. Ankota will set up Conduent during implementation upon request.

Click here for a complete walkthrough of the Conduent registration, set-up, and testing process.

Pre-Billing

Successful billing starts at the beginning of the client's creation. The processes below will lead to successful billing.

Client Management
- Client/Caregiver Entry
- Setting Authorized Service for Clients (entering authorizations)
  - In VA, if a client receives services from a live-in caregiver and a regular caregiver, the decision whether they need an extra authorization for those live-in services is determined by the Payer. Each payer may handle the situation differently. Agencies are advised to reach out to case managers and/or Payer in this case (Sentara, Anthem, United Healthcare, etc....).
- Schedule Visits - Calendar-Based Scheduling (or for those who prefer the classic approach, Creating Visits from Patterns)
Visit Management
- Caregivers complete visits or timesheets are entered manually through the office
  - Critical note: For accurate DMAS reporting, when a caregiver works Respite time, they must report at least ONE Respite item. For the mobile app, they will report the Respite item using the drop-down list. For telephony, they will report a Respite code. See more here.
- Visits are approved automatically or visits are approved by office
  - More specifically, ensure visits are closed, then review and clear the Visit Approval Dashboard
  - Critical note: For NetSmart, apply Exception Codes as needed (REQUIRED if missing EVV clock-in or clock-out)
Prevention of Errors/Rejected Claims
- Watch your warnings on the Action Center (for missing auths, primary diagnosis codes, IDs, etc.) and address as needed
- Watch your warnings on the Visit Approval Dashboard and address as needed
- Ensure that name spellings, First Name/Last Name separation, Medicaid ID, admission ID (on auth), and DOBs are entered correctly

Billing Management

General Management

Successful billing starts at the beginning of the client's creation. The processes below will lead to successful billing.

Client Management
- Setting Authorized Service for Clients (entering authorizations)
- Schedule Visits - Calendar-Based Scheduling (or for those who prefer the classic approach, Creating Visits from Patterns)
Visit Management
- Caregivers complete visits or timesheets are entered manually through the office
- Visits are approved automatically or visits are approved by office
  - More specifically, ensure visits are closed, then review and clear the Visit Approval Dashboard
  - Note that NetSmart visits require Reason Codes if they are missing critical EVV data such as a clock-in, clock-out, GPS data, or telephony data
Prevention of Errors/Unmatched/Rejected Claims
- Watch your warnings on the Action Center (for missing auths, primary diagnosis codes, IDs, etc.) and address as needed
- Watch your warnings on the Visit Approval Dashboard and address as needed
- Ensure that name spellings, First Name/Last Name separation, Medicaid ID, and DOBs are entered correctly
- (And if those preventative actions fail, watch for Rejection Response Files and address those issues as needed)

NetSmart Billing

This is the detailed overview of Tellus billing.

Currently, only Anthem is required to go through NetSmart, and this is free. Providers may choose to send other billing through NetSmart for a start-up + monthly fee. (This overview includes a link to the critically important articles for reason codes and reading Tellus response files, as well as how to manage cancellations. Another helpful article is managing data exports, which clarifies single-export corrections as well as mass export corrections.)

Note: NetSmart should receive all authorizations directly from the state, so if you see a client is missing an authorization, reach out to NetSmart support right away.

Availity Billing

Availity is commonly used for Virginia MCOs. See here for a detailed overview of Availity, including billing, troubleshooting, and more.

Conduent Billing

Conduent is required for straight Medicaid billing in Virginia (although NetSmart and Availity will process them for a fee). See here for a detailed overview of Conduent, including billing, troubleshooting, and more.

Corrected Claims

Generally, claims corrections are handled one of two ways:

Update the claims in Ankota and re-send
Update the claims in the location where it was sent

We generally recommend you use the Approval Assistant to simplify your visit corrections process. Please note you should ONLY use the Duration adjustments section if there are known, strict limitations on the allowed work duration for the selected visit type.

See the NetSmart, Availity, and Conduent articles for more on these processes.

Remittance Advice Management (835s)

Remittance advice files, or 835s, may be provided in response to filing Medicaid claims. Optima normally provides 835s through the Availity portal. Think of these like state receipts of payments. If you are provided with these files, they can be uploaded to Ankota for an automatic application of payments in the A/R records. Please note Ankota does not provide 835s; if you do not receive them from the state, you will need to arrange to receive this. For more on this process, see below.

Process Remittance Advice (Upload 835 "receipts" received from MMIS into Ankota)
Post Manual Payments
Review Billing Reports
- See also: Collections Report, Exceptions Report

Further Details

These additional resources may also be of use: