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Virginia - Transitional Assistance Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

In Virginia, Transition Services are funded through the Commonwealth Coordinated Care Plus (CCC Plus) Waiver and the Developmental Disabilities (DD) Waivers to cover up to $5,000 in one-time setup expenses for Medicaid members moving from nursing facilities or ICF/IIDs into community homes. The Department of Medical Assistance Services (DMAS) oversees the service, but the day-to-day administration and reimbursement are handled primarily through the state's managed care system.

Because DMAS transitioned most long-term services and supports into the Cardinal Care Managed Care (CCMC) program, providers must secure active network contracts with the state's designated Managed Care Organizations (MCOs) to receive reimbursement for CCC Plus members. Applicants must first enroll through the Provider Services Solution (PRSS) portal as an atypical or standard HCBS provider before initiating credentialing with these health plans.

1. Service Definition and Scope

Transition Services in Virginia provide financial assistance to Medicaid members transitioning from an institutional setting to a private community residence. The service covers essential, one-time expenses necessary to establish a basic household.

The service is strictly capped and cannot be used for ongoing living expenses. Providers act as coordinators and purchasers, securing the approved items and services on behalf of the member and billing Medicaid or the MCO for reimbursement.

2. Regulatory and Oversight Agencies

The Virginia Department of Medical Assistance Services (DMAS) is the state Medicaid agency responsible for waiver policy and provider enrollment. DMAS contracts with Gainwell Technologies to operate the Provider Services Solution (PRSS) portal.

For the majority of waiver participants, services are administered by Managed Care Organizations (MCOs) under the Cardinal Care Managed Care program. Providers must interact directly with these MCOs for authorizations and claims.

3. Gatekeeping Prerequisites: Who Can Even Apply

Virginia does not issue a standalone "Transition Services" license. Instead, providers must be established entities, such as Centers for Independent Living (CILs), Area Agencies on Aging (AAAs), or existing licensed HCBS agencies, with a valid National Provider Identifier (NPI) or atypical provider ID.

The absolute structural precondition for serving the CCC Plus population is MCO network contracting. A provider cannot simply enroll with DMAS and begin billing; they must be accepted into the provider networks of the Cardinal Care MCOs.

4. Licensure and Certification Requirements

Because Transition Services consist of purchasing goods and paying deposits rather than providing direct medical or personal care, the Virginia Department of Health (VDH) and Department of Behavioral Health and Developmental Services (DBHDS) do not require a specific license for this service alone.

Providers must maintain standard business credentials. If the provider also delivers direct care services like Personal Care or Respite, they must hold the appropriate underlying state license.

5. Medicaid Provider Enrollment

Enrollment is processed through the DMAS Provider Services Solution (PRSS) portal operated by Gainwell Technologies. Providers submit the Virginia Medicaid Provider Enrollment Application electronically.

Applicants must pass federal and state screening requirements. Depending on the exact provider type selected, an application fee may apply unless waived.

6. Staffing, Training and Background Checks

Staff coordinating transition services must meet general DMAS HCBS provider requirements. This ensures the safety and financial security of the waiver members.

Agencies must conduct background checks on any personnel interacting directly with members and ensure no staff are excluded from participating in federal healthcare programs.

7. Documentation, Policies and Records

Providers must maintain strict financial records because Transition Services are reimbursement-based. Every purchase must be tied to the member's approved Plan of Care.

Auditors will look for a clear paper trail connecting the authorized funds to the actual goods and services delivered to the member's new community home.

8. Billing, Rates and Claims

Transition Services are billed using specific HCPCS codes. For CCC Plus members, claims are submitted directly to the member's Cardinal Care MCO.

For DD waiver members or fee-for-service populations, claims go through the PRSS MMIS. Prior authorization is universally required before any funds are spent.

9. Approval Sequence and Timeline

The process starts with business formation, followed by PRSS enrollment, and concludes with MCO credentialing. Providers cannot bill for services until all steps are complete.

The entire sequence from initial application to active MCO contracts typically takes 3 to 6 months, depending on MCO credentialing backlogs.

10. Common Denials and Survey Findings

DMAS and MCOs audit Transition Services to ensure funds were used strictly for allowable setup costs. Financial discrepancies are the most common source of recoupment.

Providers must ensure they do not purchase items before receiving official authorization, as retroactive approvals are rarely granted.

11. Key Contacts and Resources

Providers should rely on the DMAS website, the PRSS portal, and the specific MCO provider manuals for the most current guidance on Transition Services.

Maintaining open communication with MCO provider relations representatives is essential for resolving credentialing and claims issues.

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