How to Fill Out the DMAS-225: Virginia Medicaid LTC Communication Form

The DMAS-225 form is Virginia’s Medicaid long-term care communication form. Nursing facilities, home and community-based waiver providers, hospice programs, and CCC Plus managed care organizations use it to notify the local Department of Social Services when a Medicaid recipient is admitted or discharged, dies, has an income change, or needs an adjustment to their patient pay amount.¹ The PDF is available from the Virginia DMAS website and through the Medicaid Enterprise System (MES) provider portal at vamedicaid.dmas.virginia.gov.²

When You Need to File One

Submit a DMAS-225 whenever any of the following happens to a Medicaid long-term care recipient:¹

Admission to or discharge from a nursing facility, waiver services, or hospice.
Death of the recipient.
A change in level of care or care setting that affects Medicaid coverage.
An income change, such as a Social Security cost-of-living adjustment or a pension change, that would alter the patient pay amount.
A request to deduct medically necessary items or services from the patient pay amount.

File promptly. Late submissions push the state’s records out of sync with what the facility is actually billing, and that creates overpayments or underpayments the resident eventually has to reconcile.

Filling Out the Form

The top of the form identifies the recipient. Enter the individual’s full name, date of birth, and 12-digit Medicaid member ID number. The form does not ask for a Social Security number; the Medicaid ID is the primary identifier. If eligibility is still pending and you don’t have the ID at initial admission, note that on the form so the eligibility worker can locate the case manually.¹

The provider section requires your facility’s National Provider Identifier (NPI) and direct contact information for the staff person submitting the form, so the eligibility worker can reach you with questions.¹

The body of the form records the specific event. For admissions and discharges, use exact dates. For income changes, list the new amount and its source. Patient pay adjustment requests carry additional documentation requirements, covered below.

Attach the DMAS-96 for a First Admission

When a resident is first admitted to a long-term care setting, the DMAS-225 must be accompanied by a copy of the DMAS-96, the pre-admission screening authorization that documents clinical eligibility for Medicaid-funded long-term services and supports.¹ Without it, the local DSS may not be able to process the admission or start the patient pay calculation.

Patient Pay Adjustment Requests

The patient pay amount is what the resident contributes toward their care each month. Virginia calculates it by taking total monthly income and subtracting allowed deductions such as the personal needs allowance and health insurance premiums; the remainder goes toward the cost of care, and Medicaid pays the balance.³

The DMAS-225 is also how a provider requests a deduction from patient pay for medically necessary items or services Medicaid doesn’t cover. These must be resident-specific and customized, such as motorized wheelchairs, specialized equipment, or hearing aid repairs. Routine supplies that the facility is expected to furnish as part of standard care don’t qualify. The provider must first pursue Medicare, private insurance, or any other third-party source before requesting an adjustment.⁴

An adjustment request must include:⁴

The recipient’s correct Medicaid identification number.
A current physician’s order for the noncovered service.
Medical justification identifying the diagnosis, functional limitation, quantity needed, and how the item will be used.
The actual cost of the item or service.
Proof that other insurance denied coverage or does not cover the item.
A copy of the most current Minimum Data Set (MDS) and quarterly review.

Only DMAS or DSS can authorize the adjustment. The facility cannot reduce the patient pay amount on its own.⁴

Where to Send It

Routing depends on whether the member is in CCC Plus managed care or fee-for-service Medicaid:¹

Nursing facility residents in CCC Plus: send the original to the MCO.
Waiver services recipients in CCC Plus: send the original to the MCO Care Coordinator.
Hospice recipients in CCC Plus: send the original to the MCO.
Fee-for-service members: send the original to the nursing facility or hospice provider, as applicable.

CCC Plus Care Coordinators also have to tell the local DSS the resident’s actual home address when it differs from the facility address, along with the FIPS code.¹ An incorrect FIPS code routes the case to the wrong local DSS office and delays processing.

How to Submit

Providers can access the MES portal at vamedicaid.dmas.virginia.gov to download forms and handle provider functions.² In practice, many facilities still fax the DMAS-225 to the local DSS office handling the member’s case. When faxing, include a cover sheet with the resident’s name and Medicaid ID so the eligibility worker can locate the file quickly.

Direct the form to the specific eligibility worker assigned to the case whenever possible. A general intake line adds routing time and increases the chance the form sits unprocessed through a billing cycle. Whether you submit electronically or by fax, keep the confirmation page or portal receipt as proof of timely filing.

What Happens After You File

The eligibility worker reviews the reported change against the member’s file. For admissions, they verify the DMAS-96 and set up the patient pay calculation. For income changes or adjustment requests, they recalculate patient pay using the new figures. DSS then issues a Notice of Action to both the facility and the Medicaid member describing the specific changes made to the case.⁵

When the Notice arrives, update the facility’s internal billing to match. A mismatch between what you bill the resident and what the Notice specifies is a compliance problem worth catching immediately.

If the Patient Pay Amount Is Wrong

A resident or their representative can appeal a patient pay determination. Virginia allows Medicaid recipients to appeal any action that denies, reduces, or ends coverage or benefits. Appeals go to the DMAS Appeals Division and can be filed:

Online at dmas.virginia.gov/appeals/
By email to appeals@dmas.virginia.gov
By phone at (804) 371-8488 (TTY: 1-800-828-1120)
By fax at (804) 452-5454
By mail or in person at Appeals Division, Department of Medical Assistance Services, 600 E. Broad Street, Richmond, VA 23219

Include a full copy of the Notice of Action with the appeal request, along with income records, medical expense receipts, insurance denial letters, or other documents showing why the calculation is incorrect.⁶ An impartial reviewer examines the case and issues a written decision. If the appeal is denied, the recipient can seek further review through the courts.

1
Virginia Department of Medical Assistance Services. DMAS-225 Virginia Medicaid LTC Communication Form
2
MES – Virginia.gov. MES – Virginia.gov
3
Virginia Code Commission. Virginia Administrative Code 12VAC30-130-610 – Purpose and Scope
4
Virginia Code Commission. Virginia Administrative Code 12VAC30-130-620 – Limitations
5
Department of Medical Assistance Services. Commonly Asked Questions
6
CoverVA – Virginia.gov. Appeals