The DMAS-100 form is Virginia Medicaid’s “Request for Supervision Hours in Personal Care” — the document a personal care provider completes to ask the participant’s managed care organization (MCO) or the DMAS service authorization contractor to approve supervision hours before those hours can be reimbursed.1Virginia Department of Medical Assistance Services. Request for Supervision Hours in Personal Care It is a clinical justification form, not a Medicaid application. If you are trying to apply for Virginia Medicaid itself, that happens through the CommonHelp portal, the Cover Virginia Call Center, or your local Department of Social Services, not through this form.
A blank copy is available as a downloadable PDF from the Virginia Medicaid provider portal at vamedicaid.dmas.virginia.gov.
Who Submits the Form and When
The provider fills out and submits the DMAS-100, not the participant. It applies when a Medicaid participant already receiving personal care services needs supervision beyond hands-on assistance because they cannot safely be left alone due to cognitive impairment, physical instability, or both.
Participants are typically enrolled in one of Virginia’s long-term services and supports programs, such as the Commonwealth Coordinated Care Plus (CCC Plus) Waiver, which provides community-based long-term care services to eligible individuals of all ages.2CoverVA. Long-Term Services and Supports Coverage and an authorized level of care have to be in place before supervision hours can be requested on top.
Section I: Documenting Why Supervision Is Needed
Section I is the heart of the form, and vague or incomplete answers here are the most common reason a request stalls. It has three parts.
Part A: Cognitive Status
Describe the participant’s cognitive status and how it affects behavior. Answer directly: can the participant be left alone safely, and if so, for how long? If confusion comes and goes during the day, spell out those patterns. Address whether the participant has appropriate judgment and decision-making ability.1Virginia Department of Medical Assistance Services. Request for Supervision Hours in Personal Care
The form defines cognitive impairment as a severe deficit in mental capability affecting thought processes, problem-solving, judgment, memory, or comprehension, and that interferes with reality orientation, self-care, recognition of danger, or impulse control. Tie observed behaviors to that definition. Describe what the participant actually does when unsupervised that creates a safety risk, rather than relying on a diagnosis label.
Part B: Physical Incapacity
This is the longest section and covers seven categories. Each one asks for specific clinical detail:
- Incontinence: the frequency of both bowel and bladder changes.
- Mobility and transfers: whether the participant can change position, shift weight, or transfer without help, plus the method of mobility (wheelchair, walker, ambulation with or without assistive devices).
- Skin breakdown: current affected areas, documented problems within the past year with dates, and whether future risk is temporary or ongoing based on incontinence frequency, ability to reposition, and skin history.
- Falls: any falls in the past three months, including dates, times, circumstances, medication interactions that may have contributed, and the interventions put in place to prevent recurrence.
- Unstable medical conditions: current diagnoses and how they relate to the need for supervision.
- Seizures: frequency and severity over the past three months.
- Children age 12 and under: a description of support needs that prevent participation in traditional child care arrangements.
The falls entry trips up many providers. “Participant fell twice” will not satisfy reviewers. Document each fall in full: time of day, what the participant was doing, whether medications played a role, and what changed afterward. That level of detail is what the MCO uses to decide whether supervision hours are medically justified.1Virginia Department of Medical Assistance Services. Request for Supervision Hours in Personal Care
Part C: Ability to Call for Help
A yes-or-no question: can the participant call for assistance by telephone? If no, explain why. That answer directly shapes how many unsupervised hours the reviewer considers safe.
Section II: Who Else Is in the Home
Section II documents who provides oversight when paid aides are not present. Reviewers compare this with Section I to find the gaps where paid supervision is needed.
For the primary caregiver, give the name, phone number, and whether that person lives with the participant. If the caregiver lives in the home, state whether they work outside the home, including the employer’s name, phone number, and the caregiver’s work schedule — when they leave and when they return.1Virginia Department of Medical Assistance Services. Request for Supervision Hours in Personal Care
List every adult age 18 or older living in the home and specify the days and times each person is away and unable to supervise. The MCO looks at those schedules to identify windows with no informal caregiver available. Those windows are the hours most likely to be approved for paid supervision. Thin answers here produce thin authorizations.
Where to Send the Form and When Services Can Start
The completed DMAS-100 goes to the participant’s MCO or the DMAS service authorization contractor, depending on how the participant’s care is managed. The MCO or contractor has to approve the request before DMAS will reimburse the provider for supervision services.1Virginia Department of Medical Assistance Services. Request for Supervision Hours in Personal Care
Do not start delivering supervision hours before authorization is in hand. Unapproved hours will not be reimbursed. Keep a copy of the submitted form in the participant’s file so you can respond quickly if the MCO asks for clarification or additional clinical documentation.
If the Request Is Denied
When an MCO denies supervision hours, the participant has the right to appeal any action that denies, reduces, or terminates services.3Department of Medical Assistance Services. DMAS Appeals Start with the MCO’s internal appeal process. If the MCO upholds the denial on internal review, the participant or provider can file a second-level appeal through the DMAS Appeals Information Management System (AIMS) portal.
Before appealing, read the denial letter against the submitted DMAS-100. A denial often means the clinical documentation was thin rather than that the participant doesn’t qualify. If the letter points to a specific physical or cognitive need the reviewer could not verify, resubmitting with stronger evidence — dated fall reports, physician notes on cognitive decline, an updated medication list — can resolve the problem faster than a formal appeal.