Virginia Medicaid Denied? Appeal Through DMAS, Medallion 4.0, and Cardinal Care

Virginia Medicaid covers over 2 million Virginians, with coverage expanded in 2019 to include low-income adults under the ACA. The Department of Medical Assistance Services (DMAS) administers the program, delivering benefits through managed care organizations. If your claim or Prior Authorization Denied: How to Appeal" class="auto-link">prior authorization was denied, Virginia's appeals system — including MCO grievances and state fair hearings — gives you a real opportunity to fight back.

How Virginia Medicaid Is Structured

Virginia operates several managed care programs:

• Medallion 4.0: The primary MCO program covering most families, children, pregnant women, and expansion adults. Contractors include Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Humana, Molina Healthcare of Virginia, and Optima Family Care.

• Cardinal Care: Serves individuals with intellectual or developmental disabilities, mental illness, or substance use disorders requiring long-term services and supports. Operated by a separate set of managed care contractors.

• Commonwealth Coordinated Care Plus (CCC Plus): Covers individuals who are dually eligible for Medicare and Medicaid, as well as individuals with complex medical needs requiring LTSS (long-term services and supports) such as home care, personal care, and nursing facility care.

• DMAS Fee-for-Service: A smaller population remains on direct fee-for-service Medicaid.

Why Virginia Medicaid Claims Are Denied

MCO denials in Virginia commonly involve:

• Medical necessity: The MCO's criteria don't align with the treating physician's judgment
• Prior authorization not obtained or denied: Required preapproval was missing or refused
• Out-of-network provider: Care received outside the MCO network without referral or emergency
• Documentation gaps: Inadequate provider records to support the claim
• Benefit exclusions: The Virginia Medicaid benefit package doesn't cover the service
• Eligibility lapses: Coverage interrupted during annual redetermination

Step 1 — File a Grievance or Appeal With Your MCO

When your MCO issues a denial, you receive an Adverse Action Notice (AAN) with the reason, criteria used, and appeal instructions.

Virginia MCO internal appeal timelines:

• Standard appeals: File within 30 days; plan responds within 30 days
• Expedited appeals: Request within 24 hours of urgent denial; plan responds within 72 hours

Submit your appeal in writing with:

• The denial letter
• Your doctor's clinical notes
• A letter of medical necessity from your treating physician
• Supporting evidence (test results, specialist opinions, guidelines)

If the MCO upholds the denial, request a state fair hearing.

Step 2 — Request a DMAS State Fair Hearing

Virginia Medicaid enrollees have the right to a State Fair Hearing before DMAS. The hearing is conducted by the Department of Medical Assistance Services' Appeals Division.

Key DMAS Fair Hearing contacts:

• DMAS Appeals Unit: 1-800-552-3431
• DMAS Form DMAS-225 (Request for State Fair Hearing): Available on the DMAS website or from your MCO

You must file within 30 days of the MCO's final decision on your internal appeal. If your benefits are being reduced or discontinued, file within 10 days of the Adverse Action Notice to request continuation of benefits while the hearing is pending.

The hearing is conducted by an impartial hearing officer. You may bring an attorney or advocate. The officer issues a written decision, and DMAS implements it. You can appeal an adverse DMAS decision to the Virginia Circuit Court.

Step 3 — Virginia Bureau of Insurance Complaint

For managed care plan conduct issues (failure to respond, procedural violations), you can also file a complaint with the Virginia Bureau of Insurance (BOI). The BOI has jurisdiction over licensed MCOs and can investigate and sanction plans for improper behavior.

Special Situations in Virginia

CCC Plus (Long-Term Services): If your personal care, home health, PERS (personal emergency response system), or other LTSS services were denied or reduced under CCC Plus, request a fair hearing immediately. These services support your ability to remain in the community.

Cardinal Care (Behavioral Health and I/DD): If your mental health, SUD treatment, or services for intellectual disabilities were denied through a Cardinal Care MCO, file a grievance with the MCO and then request a DMAS fair hearing. Behavioral health denials are commonly overturned.

ACA expansion adults: Virginia expanded Medicaid in 2019. Adults covered under the expansion have the same full appeal rights as traditional Medicaid enrollees.

EPSDT: Children under 21 in Virginia Medicaid are entitled to all medically necessary services under EPSDT. If your child's care was denied as not covered, cite EPSDT explicitly.

CCC Plus transition: If you recently transitioned to CCC Plus and your prior care is not being continued, file a grievance and a fair hearing request citing your right to continuity of care.

Fight Back With ClaimBack

Virginia's Medicaid appeal system has multiple layers, but each step is an opportunity to win. ClaimBack helps you draft a compelling DMAS appeal letter with the clinical and regulatory arguments most likely to succeed before Virginia's hearing officers.

Start your Virginia Medicaid appeal with ClaimBack

Related Reading

• Internal vs. External Insurance Appeal: Which Should You File?
• What Is Medical Necessity?
• How to Write an Insurance Appeal Letter