Virginia does not give Medicaid providers one appeal window. It gives three, depending on what DMAS did. Each runs from the provider’s receipt of the decision — and receipt is presumed three days after DMAS puts the notice in the mail.
Termination or denial of a provider agreement
Va. Code Ann. § 32.1-325(E); 12VAC30-20-540(A)(1)
Every other DMAS decision
12VAC30-20-540(A)(3)
Adjustments to a cost report
12VAC30-20-540(A)(2)
A notice date-stamped by the DMAS Appeals Division after 5:00 p.m. Eastern on the due date is untimely. 12VAC30-20-520(I).
Services were rendered and documented, and reimbursement was refused, reduced, or reversed. These are the most common provider appeals and often turn on documentation standards rather than on whether the care was necessary.
Overpayment demands and recoupment following a DMAS or contractor audit — including findings extrapolated from a sample across a much larger universe of claims. The extrapolation methodology itself is frequently the strongest ground of appeal.
Termination or denial of a Medicaid provider agreement under Va. Code Ann. § 32.1-325(E). This carries the shortest deadline in the entire scheme and can end a facility’s participation in the program.
Refusal to enroll or re-enroll a provider, including denials arising from ownership disclosures, screening levels, or prior adverse actions.
Adjustments reflected in a notice of program reimbursement. These carry a materially longer filing window than other provider appeals, which providers routinely fail to take advantage of.
Disputes with a Cardinal Care or other contracted plan, where the plan’s internal appeal or reconsideration process must ordinarily be exhausted before a DMAS appeal can proceed.
Part XII of the DMAS regulations governs every informal and formal provider appeal and supersedes any other provider appeals regulation. 12VAC30-20-520(A).
The written notice of informal appeal goes to the DMAS Appeals Division and must identify each adjustment, patient, service date, or other disputed matter. A notice that fails to identify the disputed items in the required detail is subject to administrative dismissal. 12VAC30-20-540(A), (B)(1).
DMAS has 30 days from the filing of the notice to file a written case summary explaining the factual basis and authority for its action. If DMAS misses that deadline, the regulation directs dismissal in favor of the provider. 12VAC30-20-540(C)(1), (3).
The provider then has 12 days following the case summary due date to file written notice of every deficiency in that summary. Deficiencies not raised in that window are deemed waived — all of them. 12VAC30-20-540(C)(4).
Held within 90 days of filing, in Richmond unless the parties and the appeals agent agree otherwise. It is not an adversarial or evidentiary proceeding and no party recording is permitted. Additional documentation may be filed only within the period the agent specifies, capped at 30 days. 12VAC30-20-540(D); 12VAC30-20-520(F).
Issued within 180 days of receipt of the notice of informal appeal, absent a written agreement to stay. 12VAC30-20-540(E).
Filed within 30 days of receipt of the informal decision. Only issues addressed at the informal stage may be raised, unless DMAS and the provider have agreed in writing to waive informal fact-finding. Documentary evidence is due within 21 days of filing; the hearing is held within 45 days. 12VAC30-20-560(A), (B)(1)(a), (C).
A hearing officer selected by the Executive Secretary of the Supreme Court of Virginia submits a recommended decision within 120 days. Written exceptions are due within 14 days of the DMAS director’s letter, and the director issues the final agency decision within 60 days. 12VAC30-20-560(E)–(G).
The final agency decision is reviewable in circuit court under the Virginia Administrative Process Act, Va. Code Ann. § 2.2-4000 et seq.
Most provider appeals that fail do not fail on the merits. They fail on the procedure surrounding them.
If a DMAS or contractor reconsideration, review, or internal appeal process applies and has not been exhausted, the informal appeal is administratively dismissed. 12VAC30-20-540(B)(3).
A document date-stamped by the Appeals Division after 5:00 p.m. Eastern on the due date is untimely. Not late by a day — untimely. 12VAC30-20-520(I).
Receipt is presumed three days after DMAS mails an item, and on the date of transmission for fax or email. Failing to open an item does not extend anything. 12VAC30-20-520(C).
A billing company or other third party must submit written authorization signed by the provider, or the appeal is dismissed. That requirement does not apply to an appeal filed by a Virginia licensed attorney. 12VAC30-20-540(B)(2).
Issues not addressed in the informal appeal cannot be raised in the formal appeal. The informal stage is not a warm-up. 12VAC30-20-560(A).
Failure by a party to attend results in dismissal in favor of the other party. 12VAC30-20-520(G).
Where a provider substantially prevails on the merits and the DMAS position was not substantially justified, the regulation requires DMAS to reimburse reasonable and necessary attorney fees and costs, unless special circumstances would make an award unjust. Substantially prevailing means succeeding on more than 50% of the dollar amount identified in the notice of appeal. 12VAC30-20-520(H).
Whether that standard is satisfied in any particular appeal is its own question, and no outcome can be promised. It is simply a feature of the Virginia scheme that many providers do not know exists.
It depends on what DMAS did. Termination or denial of a provider agreement carries a 15-day deadline. Cost report adjustments carry 90 days. Every other DMAS decision carries 30 days. All three run from the provider’s receipt of the decision, and receipt is presumed three days after mailing. 12VAC30-20-540(A).
Sometimes. DMAS is required to reimburse reasonable and necessary attorney fees and costs where the provider substantially prevails on the merits and the DMAS position was not substantially justified, unless special circumstances would make an award unjust. Substantially prevailing means succeeding on more than 50% of the dollar amount at issue. 12VAC30-20-520(H). Whether that standard is met in any particular appeal is a separate question.
You may appeal the DMAS interpretation and application of a payment methodology. You may not appeal the payment methodology itself. 12VAC30-20-520(B).
The sampling and extrapolation methodology is itself an appealable application of DMAS policy, and it is often where the largest dollars sit. Whether a challenge succeeds depends on the sample, the universe, and the statistical method used.
At the DMAS main office in Richmond, unless DMAS, the provider, and the informal appeals agent or hearing officer agree in writing to another location. 12VAC30-20-520(F).
Yes. Facilities frequently face a resident-side eligibility problem and a provider-side payment problem arising from the same set of facts. Both can be handled together.
The first conversation is straightforward and without obligation. If you have received a retraction demand, an audit finding, or a termination notice, the date on that notice is the first thing that matters.
Regulatory citations on this page reflect the Virginia Administrative Code as published at the time of writing and are provided for general information. Regulations change. Nothing here is legal advice, no attorney–client relationship is created by reading it or by contacting the firm, and no outcome is promised. Do not send confidential information until a relationship has been established in writing.
