Virginia Department of Medical Assistance Services

• Provider is notified approximately 3 weeks in advance of the review.
• An entrance conference is held at the onset of the review, in person or telephonically.
• A preliminary review of the documentation available for review is conducted.
• An exit conference is held at the completion of the first stage of the review.
• A Preliminary Report is issued after DMAS approval. The Preliminary Report may include a Preliminary Claims List, a Preliminary Service Log and a Preliminary Discrepancies Letter.
• If discrepancies have been identified on the Preliminary Report, the Provider is afforded 30 days to respond to the Preliminary Report. This may include additional documentation and information in response to the preliminary discrepancies that have been identified on the report.
• The Provider’s response to the Preliminary Report is then reviewed to determine if the additional documentation and information submitted resolves the discrepancies identified on the Preliminary Report.
• If discrepancies remain after review of the Provider’s response to the Preliminary Report, an Overpayment Report is issued after DMAS approval. (If the Provider does not submit a response within 30 days of the Preliminary Report, an Overpayment Report will be issued after DMAS approval.) The Overpayment Report may include an Overpayment Claims List, an Overpayment Service Log and an Overpayment Letter.
• The Overpayment Letter includes information on the Provider’s appeal rights, if the Provider disagrees with the findings within the Overpayment Report.

For Questions Regarding Preliminary and Overpayment Letters

Brandy Coleman, MHA, CHC, CPhT
Jill Tyler, LCSW
Ryan Rios, CFE
Shelly Verougstraete, CPA 

Your letter includes a narrative explanation of each discrepancy or error code. This narrative explanation provides the factual basis and relevant authority for each discrepancy or error code.

You have been provided with a “Claims List” and a “Service Log”, if needed. The “Claims List” includes: facility listing of claims reviewed, by recipient, identifying the discrepancy(s) or error(s) for each respective claim. The “Service Log” is supplemental information only for particular provider types, and has specific details for each recipient, for each date of service, that is included in the “Claims List.” To understand additional detail of the discrepancy(s) or error(s) identified in your “Claims List,” please reference each recipient’s respective “Service Log,” if needed.

Each recipient’s “Service Log” will identify the services noted during our review, according to your documentation, applicable to the claim dates of service from the facility “Claims List.” The services noted on the “Service Log” represent our understanding of all documentation provided by you, to us, during our review for the applicable dates of service. If a discrepancy or error has been identified in a service, it will be so noted in the column with a corresponding code number to the discrepancy or error code number listed on “Claims List.”