What’s happening: November marks the first billing cycle since DMAS made the transition from a RUGs-based payment system to the Patient Driven Payment Model (PDPM) based reimbursement on October 1, 2025.

• We have updates on the readiness of fee-for-service (FFS) and the managed care organizations (MCOs) to handle the transition.

The process is not running smoothly for some MCOS, and these processing problems may be compounded next week as the number of claims to be processed increases.

• Please share this information with your billing teams for their awareness.

FFS: Some VHCA-VCAL members who either bill more often than monthly or who have submitted some claims already report that FFS is processing claims correctly.

• However, one provider indicated that a “test claim” to FFS denied as “HIPPS code invalid,” so we are not yet certain and appreciate your feedback as you submit claims.

Sentara and Humana appear to be correctly processing PDPM-coded claims.

Anthem is not processing PDPM-coded claims correctly. Claims show an invalid PDPM HIPPS code rejection reason in Availity.

• Anthem has indicated it is aware of this situation and is working on a system fix that will not be complete until early 2026.
• In the interim, Anthem will be manually retrieving the rejections from the EDI database one to two times per week. Once the team retrieves the rejected claims, Anthem will adjudicate them within its system in alignment with the new PDPM structure as expected.
• Anthem has stated that no additional work will be required from the provider upon claims submission. Additionally, once a claim is adjudicated, it will follow the standard process and update appropriately within Availity with payment details.

UnitedHealthcare (UHC) is not processing PDPM-coded claims correctly and is currently working on system updates with no specific timeframe for completion.

• UHC’s interim processing approach is a manual intervention. UHC has stated that a “dedicated team is already in place to ensure claims are processed and paid accurately. Since some providers bill weekly, bi-weekly, and on other schedules, the team is actively identifying and addressing any issues as they arise.”

Aetna is not processing PDPM-coded claims correctly.

• According to Aetna via DMAS, “The edit currently impacting these claims appears to be a deeper configuration issue. We are actively collaborating with our configuration teams to identify and resolve the root cause. Internally, we are investigating a potential gap within the Pre-Check Run Query (PCQ) logic that may have triggered inappropriate denials. Our goal is to isolate and adjust the variable responsible. In the interim, the VA Health Plan Operations team is manually pricing all affected claims to ensure accurate payment. To support this, the PCQ has been temporarily updated to pend claims to Health Plan Operations for pricing and rework. We have pulled a comprehensive claims report, and all claims that were denied in error have been manually priced. These will be processed through the adjustment workflow tomorrow and are scheduled to pay in the next cycle on 10/31/2025.”
• VHCA-VCAL has relayed concerns to DMAS that the claims volume will increase exponentially in the coming week and requested an estimate on when the correct configuration would be in place without receiving a further substantive response.

Contact Steve Ford if your claims processing experience differs from what is outlined above.

• VHCA-VCAL will be closely monitoring how these issues are resolved and reach out to DMAS for assistance as needed.

Of note: For the MCOs implementing manual processes, DMAS indicates these MCOs are still held accountable to processing timelines. Please keep Steve Ford informed on how that is going as well.