To fill out the DMAS-97A/B, list the member’s Medicaid ID and diagnoses, check only the care tasks that match a documented functional limitation, assign a time increment to each task so the daily and weekly totals stay within the member’s Level of Care hour cap, and collect the physician, member, and provider signatures the situation calls for before sending the form to the member’s managed care organization or the Virginia Medicaid fiscal agent. The form authorizes home and community-based waiver services, and every approved task and hour is tied to the member’s Level of Care score, so precision on the page is what keeps care flowing.
What to Have in Front of You
Before opening the form, gather the member’s Medicaid identification number, their primary and secondary medical diagnoses, the results of their most recent functional assessment (the Activities of Daily Living scoring that determines Level of Care), and a realistic picture of what the caregiver will actually do at each visit. You also need the current version of the form itself. The most recent revision is dated April 2019 and is available through the Virginia Medicaid web portal at vamedicaid.dmas.virginia.gov, or from the member’s assigned MCO.1Virginia Code Commission. 12VAC30-120 – Forms Check the revision date in the lower-left corner. An outdated form causes processing delays.
Member Information and Diagnoses
Enter the member’s full name, Medicaid ID, and all relevant medical diagnoses on page one. The diagnoses have to line up with the functional limitations shown in the ADL assessment. If the diagnosis is congestive heart failure and the assessment documents difficulty with bathing, mobility, and meal preparation, those are the limitations that belong on the form. When the diagnoses and the task checkboxes don’t tell the same story, the request gets denied.
Service Tasks and Time Allocation
The heart of the form is a checklist of specific care tasks: bathing, dressing, toileting, medication reminders, meal preparation, transfers, mobility, and similar items. Check only the tasks the caregiver will actually perform, and assign a time increment to each one. The point of this section is to translate the member’s medical picture into a concrete daily and weekly schedule.2Virginia Department of Medical Assistance Services. DMAS-97A/B Agency or Consumer Directed Provider Plan of Care
Two habits will keep the form clean. First, every checked box should trace back to either a diagnosis or a functional limitation in the assessment. Tasks that look helpful but have no clinical basis get flagged. Second, add the task times carefully. The daily total across all tasks, when rolled up to a week, cannot exceed the hour cap for the member’s Level of Care.
Staying Within the Level of Care Hour Cap
The form’s structure revolves around three Level of Care designations, each with a scoring range and a weekly hour ceiling:
- LOC A (score 0–6): up to 25 hours per week.
- LOC B (score 7–12): up to 30 hours per week.
- LOC C (score 9 or higher with wounds, tube feedings, or similar clinical needs): up to 35 hours per week.
The total daily time you allocate across every checked task cannot exceed the member’s LOC weekly cap.2Virginia Department of Medical Assistance Services. DMAS-97A/B Agency or Consumer Directed Provider Plan of Care This is where most authorization problems start. If the hours on the form exceed the cap, the request will not be processed. Any increase that pushes past the current LOC cap, or any change to the LOC category itself, has to be authorized by DMAS or the designated service authorization contractor before the higher level of care can begin.3Virginia Code Commission. 12VAC30-120-930 – General Requirements for Home and Community-Based Services An increase that stays within the existing LOC cap can be implemented before formal approval.
Signatures You Need
Three parties sign a completed DMAS-97A/B, and the rules are more specific than most people expect.
The physician signs a certification of medical necessity confirming that the services are clinically appropriate. Without that endorsement, Medicaid will not reimburse the provider. For private duty nursing, the physician’s signature must be renewed every 60 days, and the recertification has to be signed within the last five business days of the current 60-day period.4Virginia Code Commission. 12VAC30-120-935 – Participation Standards for Specific Covered Services
The member or a legally authorized representative signs the original plan of care. A member signature is also required any time the plan is revised to decrease hours. If the revision increases hours, the member’s signature is not required, but the provider should document the member’s acceptance in the record.2Virginia Department of Medical Assistance Services. DMAS-97A/B Agency or Consumer Directed Provider Plan of Care
The service provider (the personal care agency, the consumer-direction services facilitator, or the nursing provider) signs to confirm that the described care will be delivered.
Where to Send the Completed Form
Where the signed form goes depends on how the member receives Medicaid. Most Virginia waiver members are enrolled in a managed care organization, and for those members the DMAS-97A/B is uploaded through the MCO’s secure provider portal or submitted according to the MCO’s specific instructions. Confirm the member’s current MCO before sending anything, because Virginia’s managed care assignments have shifted over recent years.
For fee-for-service members not enrolled in an MCO, send the form to the Virginia Medicaid Fiscal Agent, P.O. Box 26228, Richmond, Virginia 23260-6228, or fax it to (888) 335-8460.
Submit promptly once every signature is in hand. If there is a gap between the end of the current authorization and the processing of a new plan, the member has no approved services during that window, and the provider cannot bill for care delivered without authorization. After approval, the provider receives a service authorization number that goes on every claim tied to the plan.
When the Form Has to Be Redone
The DMAS-97A/B is required at the initial assessment when a member enters a waiver program. After that, the provider must review and update the plan at least annually, and any significant change in the member’s condition or support system triggers a revision outside the regular schedule. For agency-directed personal care, a registered nurse supervisor reassesses the member and reviews the plan at least every 90 days; for consumer-directed personal care, the services facilitator reviews on the same 90-day cycle, annually, and more often as needed. Private duty nursing runs on a 60-day recertification cycle as described above.4Virginia Code Commission. 12VAC30-120-935 – Participation Standards for Specific Covered Services
If the Plan Is Denied or Reduced
Members can appeal any action that denies, reduces, or terminates services. When a provider decreases authorized care, the member must be notified by letter, and that letter has to state the right to appeal.3Virginia Code Commission. 12VAC30-120-930 – General Requirements for Home and Community-Based Services Appeals can be filed through the DMAS appeals portal 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, or by mail or in person to the Appeals Division, Department of Medical Assistance Services, 600 E. Broad Street, Richmond, VA 23219. Include a full copy of the notice of action along with any supporting documents.5CoverVA. Appeals
A member already receiving services who files a timely appeal before a proposed reduction or termination takes effect can request that the current level of services continue while the appeal is pending. Filing quickly is the single most important step for avoiding a gap in care.