Waiver Consulting Group — Start any program. In any state.

Virginia - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Virginia Department of Behavioral Health and Developmental Services (DBHDS) licenses Support Coordination/Case Management under 12VAC35-105, serving as the mandatory entry point for individuals accessing the state's Developmental Disability (DD) waivers. This service encompasses functional assessment, person-centered Individualized Services Plan (ISP) development, service linkage, and ongoing monitoring to ensure health and safety in the community.

Private agencies seeking to provide DD Support Coordination face a closed-network statutory framework, as the Code of Virginia designates local Community Services Boards (CSBs) and Behavioral Health Authorities (BHAs) as the exclusive operating entities for this service. Independent providers cannot enroll directly with Medicaid as standalone DD case managers; they must instead secure a formal subcontract or affiliation agreement with a local CSB that holds the primary Medicaid provider agreement for that catchment area.

1. Service Definition and Scope

In Virginia, Case Management (frequently termed Support Coordination for DD populations) is defined as services that assist individuals in gaining access to needed medical, social, educational, and other services. The service does not include the direct delivery of medical or clinical treatments, but rather the orchestration of the individual's entire HCBS waiver package.

The scope of practice requires the case manager to conduct initial and ongoing assessments, develop the ISP, link the individual to qualified waiver providers, and conduct regular face-to-face monitoring visits to verify that services are delivered according to the ISP and meet the individual's changing needs.

2. Regulatory and Oversight Agencies

Two primary state agencies govern case management services in Virginia. DBHDS handles the programmatic licensing, regulatory compliance, and quality oversight for all behavioral health and developmental disability services.

The Department of Medical Assistance Services (DMAS) serves as the state Medicaid agency, managing provider enrollment, establishing reimbursement rates, and operating the Medicaid Enterprise System (MES) for claims processing.

3. Gatekeeping Prerequisites: Who Can Even Apply

Virginia strictly limits who can provide DD Support Coordination. By statute, the 40 local Community Services Boards (CSBs) and Behavioral Health Authorities (BHAs) are the designated entities responsible for DD case management. A private entity cannot simply apply for a DBHDS license and DMAS enrollment to offer DD Support Coordination independently.

To operate in this space, a private agency must first secure a subcontract with a local CSB. The CSB retains the ultimate authority and Medicaid billing rights, delegating the operational duties to the subcontractor. Without this executed agreement, DMAS will not enroll the provider for DD case management.

4. Licensure and Certification Requirements

Providers must obtain a license from the DBHDS Office of Licensing under the administrative code 12VAC35-105. The application process requires submission of a comprehensive policy and procedure manual, proof of financial stability, and a detailed service description.

The DBHDS licensing process includes an initial application review followed by an on-site inspection. Providers must demonstrate compliance with human rights regulations, incident reporting protocols, and physical environment standards if operating a facility, though case management is primarily community-based.

5. Medicaid Provider Enrollment

Once licensed by DBHDS and holding the necessary CSB affiliation (if applicable), providers must enroll with DMAS through the Medicaid Enterprise System (MES) Provider Registration and Service Authorization System (PRSS).

Enrollment requires an active National Provider Identifier (NPI), completion of a Participation Agreement, and successful provider screening. Out-of-state providers must be screened by their home state Medicaid program or Medicare prior to applying in Virginia.

6. Staffing, Training and Background Checks

Virginia mandates strict educational and experiential qualifications for case managers. Staff must typically meet the criteria for a Qualified Developmental Disabilities Professional (QDDP) or a Qualified Mental Health Professional (QMHP), depending on the target population.

Training requirements are rigorous and time-sensitive. DBHDS requires specific core competency training to be completed immediately upon hire, and all staff must pass comprehensive criminal background checks and central registry checks before providing direct services.

7. Documentation, Policies and Records

Case management providers must maintain exhaustive clinical and administrative records. The cornerstone of this documentation is the Individualized Services Plan (ISP), which must clearly link assessed needs to specific waiver services and goals.

Providers must also maintain detailed progress notes for every billable encounter. These notes must document the date, time, duration, location, and specific interventions provided, aligning directly with the objectives outlined in the ISP.

8. Billing, Rates and Claims

Reimbursement for case management services is processed through the DMAS MES using standard HIPAA-compliant transactions. Rates are established by the Virginia General Assembly and published in the DMAS fee schedules.

Billing is typically conducted on a monthly unit basis, requiring a minimum number of qualifying contacts (including face-to-face visits) to generate a billable claim. Providers must ensure that no duplicate billing occurs across different waiver programs.

9. Approval Sequence and Timeline

The pathway to becoming a billable provider is strictly sequential. An applicant cannot apply for Medicaid enrollment until the DBHDS license is fully issued, and for DD services, the CSB contract must be secured first.

The entire process from initial DBHDS application to active DMAS billing status typically takes 6 to 9 months, heavily dependent on the completeness of the policy manual submission and the scheduling of the initial licensing site visit.

10. Common Denials and Survey Findings

Licensing applications are frequently delayed due to incomplete or generic policy manuals that fail to address Virginia-specific regulations, particularly regarding human rights and incident management.

During compliance surveys, the most common citations involve missing or late DBHDS core competency training certificates, ISPs that lack measurable goals, and progress notes that do not adequately justify the billed time.

11. Key Contacts and Resources

Prospective providers should rely exclusively on official state resources for the most current regulations, forms, and fee schedules. The DBHDS and DMAS websites house all necessary manuals and portal links.

For DD case management specifically, the local CSB in the intended service area is the most critical initial contact, as they control network access.

See all Virginia services · Virginia Medicaid consulting · book a consultation.