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

Last reviewed: 2026-08-16

In Virginia, Case Management Services (often referred to as Support Coordination in developmental disability contexts) encompass comprehensive assessment, person-centered Individualized Service Plan (ISP) development, referral to community resources, and ongoing monitoring of a Medicaid member's full service package. These services are critical components of Virginia's behavioral health system, Early Intervention programs, and Home and Community-Based Services (HCBS) waivers, including the Developmental Disabilities (DD) Waivers and the Commonwealth Coordinated Care (CCC) Plus Waiver.

The single biggest structural barrier to entry for prospective case management providers in Virginia is the strict sequencing of state approvals and statutory monopolies. A provider cannot even submit a Medicaid enrollment application to the Department of Medical Assistance Services (DMAS) without first obtaining a full, active provider license from the Department of Behavioral Health and Developmental Services (DBHDS). Furthermore, for the DD Waiver populations, Virginia law restricts Support Coordination (case management) almost exclusively to the state's 40 local Community Services Boards (CSBs); private entities are structurally blocked from enrolling as standalone DD case managers unless they secure a specific subcontracting arrangement with a local CSB.

1. Service Definition and Scope

Case Management in Virginia is defined as services that assist individuals in accessing needed medical, psychiatric, social, educational, and other supports essential to meeting basic needs. The service does not include the direct delivery of medical or clinical treatments, but rather focuses on the coordination and monitoring of the individual's overall care package across multiple systems.

The scope of case management varies by target population, with distinct regulatory frameworks for Mental Health (MH) Case Management, Developmental Disabilities (DD) Support Coordination, and Early Intervention (EI) Case Management. Providers must adhere to the specific service definitions outlined in the DMAS program manuals for their respective populations.

• Core Components: Comprehensive needs assessment, person-centered ISP development, linkage to community resources, and continuous monitoring of service efficacy.
• Target Populations: Individuals with serious mental illness (SMI), children with serious emotional disturbance (SED), individuals with developmental disabilities, and infants/toddlers requiring early intervention.
• Waiver Integration: Case management is a mandatory, foundational service for participants in Virginia's DD Waivers (Building Independence, Family & Individual Supports, Community Living) and the CCC Plus Waiver.
• Service Exclusions: Case management cannot duplicate other Medicaid-funded care coordination, such as MCO-provided care coordination or direct therapeutic interventions.

2. Regulatory and Oversight Agencies

Virginia utilizes a bifurcated oversight model for Medicaid HCBS and behavioral health services. Programmatic licensing, quality management, and human rights oversight are handled by the Department of Behavioral Health and Developmental Services (DBHDS).

Financial oversight, provider enrollment, and claims processing are managed by the Department of Medical Assistance Services (DMAS) and its contracted Cardinal Care Managed Care Organizations (MCOs). Providers must maintain compliance with both state agencies simultaneously.

• Licensing Authority: Virginia Department of Behavioral Health and Developmental Services (DBHDS) at https://dbhds.virginia.gov/
• Medicaid Agency: Virginia Department of Medical Assistance Services (DMAS) at https://www.dmas.virginia.gov/
• Enrollment Portal: Medicaid Enterprise System (MES) Provider Services Solution (PRSS) at https://virginia.hppcloud.com/
• Managed Care Oversight: Cardinal Care Managed Care Organizations (MCOs) at https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care/

3. Gatekeeping Prerequisites: Who Can Even Apply

Virginia imposes severe structural preconditions that block applicants before a Medicaid enrollment application can be initiated. The most significant is the statutory monopoly granted to local government entities for specific populations, alongside strict prior-licensure mandates.

If an applicant attempts to bypass DBHDS licensure or apply for a restricted service without the proper local affiliation, the DMAS PRSS system will automatically reject the enrollment attempt.

• Statutory Monopoly for DD: Developmental Disability Support Coordination is statutorily restricted to Virginia's 40 local Community Services Boards (CSBs) or Behavioral Health Authorities (BHAs); private entities cannot enroll as DD case managers unless explicitly subcontracted by a CSB.
• Prior Licensure Mandate: An active DBHDS license for the specific case management service must be fully approved and issued before a DMAS PRSS enrollment application will be accepted.
• Local Zoning Approval: DBHDS requires proof of local zoning compliance for any physical administrative office locations prior to accepting a licensure application.
• Priority Service Review: DBHDS requires new applicants for Priority 1 or 2 services to complete specific pre-application orientations and readiness reviews before an application is processed.

4. Licensure and Certification Requirements

Licensure for case management is governed by the Virginia Administrative Code, specifically 12VAC35-105. Providers must submit a comprehensive application to the DBHDS Office of Licensing, demonstrating robust operational policies, financial solvency, and adherence to human rights regulations.

The licensure process includes a rigorous review of the provider's business plan, service descriptions, and a mandatory on-site inspection of the administrative office before a conditional or annual license is granted.

• Regulatory Citation: 12VAC35-105 (Rules and Regulations for Licensing Providers by the Department of Behavioral Health and Developmental Services).
• Application Components: Submission of the DBHDS Initial Provider Application, including a business plan, working budget, and comprehensive policy manual.
• Human Rights Compliance: Providers must establish policies compliant with 12VAC35-115 and affiliate with a DBHDS Local Human Rights Committee (LHRC).
• On-Site Inspection: A DBHDS licensing specialist will conduct an on-site inspection of the physical office to verify administrative readiness and secure record storage.
• Early Intervention Certification: Providers of Early Intervention case management must be specifically certified as Early Intervention Case Managers by DBHDS, per [Part IV. Case Management Services](https://law.lis.virginia.gov/admincodefull/title12/agency30/chapter50/partIV/).

5. Medicaid Provider Enrollment

Following DBHDS licensure, providers must enroll as billing entities through the DMAS Provider Services Solution (PRSS) portal. Under the federal 21st Century Cures Act, all providers must enroll directly with DMAS, even if they intend to bill exclusively through Cardinal Care MCO networks.

The PRSS application requires precise alignment of legal business names, tax identification numbers, and licensure data. Any discrepancy between the IRS W-9, the DBHDS license, and the PRSS application will result in immediate denial.

• System Access: Applications must be submitted electronically via the MES PRSS portal at [New Enrollment - Medicaid](https://virginia.hppcloud.com/ProviderEnrollment/EnrollmentCreate).
• NPI Requirement: Providers must obtain a Type 2 (Organization) National Provider Identifier (NPI) via NPPES prior to application.
• Payment Infrastructure: Mandatory Electronic Funds Transfer (EFT) authorization and a certified IRS W-9 form are required; EFT is the only payment method available through Virginia Medicaid.
• MCO Credentialing: After PRSS approval, providers must separately credential and contract with Virginia's Cardinal Care MCOs to serve managed care members.
• Revalidation: DMAS requires provider revalidation every 5 years (or 3 years for high-risk categories), initiated 90 days prior to the end of the enrollment period, per [Provider Enrollment & Revalidation](https://www.dmas.virginia.gov/for-providers/provider-enrollment-revalidation).

6. Staffing, Training and Background Checks

Virginia strictly regulates the qualifications of individuals performing case management. Staff must meet specific educational and experiential thresholds defined by DBHDS and the Virginia Department of Health Professions.

Comprehensive background checks are mandatory before any staff member can provide direct services or access sensitive Medicaid member data.

• Mental Health Qualifications: Staff must meet the criteria for a Qualified Mental Health Professional (QMHP-A or QMHP-C) and be actively registered with the Virginia Board of Counseling.
• DD Qualifications: Staff must meet the criteria for a Qualified Developmental Disabilities Professional (QDDP) as defined in [12VAC35-105-1250. Qualifications of case management employees or contractors.](https://law.lis.virginia.gov/admincode/title12/agency35/chapter105/section1250/).
• Criminal Background Checks: Mandatory fingerprint-based criminal history checks via the Virginia State Police and the FBI for all direct care staff.
• Child Abuse Registry: Central Registry checks through the Virginia Department of Social Services (VDSS) are required for any staff serving children or adolescents.
• Competency Training: DBHDS requires documented, ongoing training on human rights, person-centered planning, and incident reporting protocols.

7. Documentation, Policies and Records

Case management providers must maintain highly detailed, auditable records that demonstrate medical necessity, active service planning, and continuous monitoring. DMAS and DBHDS conduct routine audits, and poor documentation is the leading cause of Medicaid clawbacks.

All service documentation must clearly link the case manager's activities to the specific goals and objectives outlined in the member's Individualized Service Plan (ISP).

• Individualized Service Plan (ISP): Must be developed within 30 days of admission, detailing specific, measurable goals, interventions, and timeframes.
• Progress Notes: Every billed encounter must be supported by a progress note detailing the date, duration, specific activity performed, and its direct relationship to the ISP.
• Incident Reporting: Providers must use the DBHDS Computerized Human Rights Information System (CHRIS) to report serious incidents and human rights complaints within 24 hours.
• Record Retention: DMAS requires all Medicaid records, including ISPs and progress notes, to be retained for a minimum of 5 years from the date of service.
• Back-up Planning: Providers must maintain written back-up plans to ensure participants receive continuous case management services if the assigned case manager is unavailable.

8. Billing, Rates and Claims

Case management in Virginia is typically billed in monthly bundles or 15-minute increments, depending on the specific waiver or behavioral health program. Claims are processed either through the MES Electronic Data Interchange (EDI) for Fee-For-Service members or directly to the respective Cardinal Care MCO clearinghouses.

Providers must ensure that all billing is supported by documented, substantive contact with the member or their collateral contacts during the billing period.

• Common Codes: T1016 (Case Management, each 15 minutes) or specific monthly bundled codes (e.g., H0006 for MH case management), depending on the exact program.
• Active Month Requirement: For monthly billed case management, DMAS requires documentation of at least one meaningful face-to-face or substantive contact during the calendar month to justify the claim.
• Rate Setting: DMAS establishes fee schedules annually; Fee-For-Service rates are published on the DMAS website, while MCO rates are negotiated but generally floor at the Medicaid fee schedule.
• Claim Submission: Claims must be submitted electronically via the MES portal or the applicable MCO's designated clearinghouse within timely filing limits (typically 365 days for FFS, but often 90-120 days for MCOs).

9. Approval Sequence and Timeline

Becoming a fully approved and billing case management provider in Virginia is a lengthy, multi-phase process. Providers must sequence their applications perfectly, as neither DMAS nor the MCOs will process applications without the preceding agency's approval.

From initial business formation to the first paid claim, the entire process typically takes between 6 and 12 months, heavily dependent on DBHDS licensing queues.

• Phase 1 (Business Setup): Register with the State Corporation Commission (SCC), obtain an EIN, NPI, and secure commercial liability insurance (1-2 months).
• Phase 2 (DBHDS Licensure): Submit the DBHDS application, undergo policy review, and pass the on-site inspection (typically 3-6 months, subject to state backlog).
• Phase 3 (DMAS PRSS Enrollment): Submit the electronic application via PRSS; processing takes up to 10-15 business days per [VA Medicaid Provider Enrollment 2026: Complete DMAS PRSS Guide](https://medsolercm.com/blog/va-medicaid-provider-enrollment).
• Phase 4 (MCO Credentialing): Contract and credential with the Cardinal Care MCOs (90-120 days post-DMAS approval).

10. Common Denials and Survey Findings

Applications and claims are frequently denied due to administrative mismatches or failure to adhere to strict DBHDS and DMAS documentation standards. Precision in application data entry and clinical documentation is essential.

During audits, state surveyors heavily scrutinize the linkage between billed time and the specific interventions outlined in the ISP.

• Enrollment Denials: Name mismatches between the IRS W-9, DBHDS license, and PRSS application are the single most common cause of DMAS enrollment rejection.
• Licensure Delays: Submitting incomplete human rights policies or failing to secure local zoning approvals prior to DBHDS application submission.
• Claim Denials: Billing for case management in a month where no substantive, documented contact occurred, or billing before the ISP is fully signed and authorized.
• Audit Findings: Utilizing generic, cloned progress notes that do not clearly link to the specific, individualized goals outlined in the member's ISP.
• MCO Rejections: Attempting to credential with a Cardinal Care MCO before receiving final DMAS PRSS approval.

11. Key Contacts and Resources

Prospective providers must utilize the official state portals and regulatory resources to navigate the licensure and enrollment process. Relying on outdated manuals or third-party summaries can lead to compliance failures.

The following official Virginia resources are essential for establishing and maintaining a case management agency.

• DBHDS Office of Licensing: https://dbhds.virginia.gov/quality-management/Office-of-Licensing
• DMAS Provider Portal (PRSS): https://virginia.hppcloud.com/
• DMAS Provider Enrollment Information: https://www.dmas.virginia.gov/for-providers/provider-enrollment-revalidation
• Virginia Administrative Code (12VAC35-105): https://law.lis.virginia.gov/admincode/title12/agency35/chapter105/
• Gainwell PRSS Hotline: 1-888-829-5373 (for Application Tracking Number recovery and enrollment assistance).

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