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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 April 2019 Subchapter Subject Page ending with Page M0110.000 GENERAL INFORMATION M0110.100 2

C. Agency Responsibilities 1. DMAS The administrative responsibilities of DMAS are:

• the development of the State Plan to cover eligibility criteria and scope of services, in conformity with federal law and regulation,

• the determination of medical care covered under the State Plan,

• oversight of the Cover Virginia Call Center, the Central Processing Uni (CPU), which handles telephonic applications for MA, and the Cover Virginia Incarcerated Unit (CVIU).

• the handling of appeals related to the MA programs,

• the approval of providers authorized to provide medical care and receive payments under the MA programs,

• the processing of claims and making payments to medical providers, and • the recovery of MA expenditures in appropriate cases. Suspected applicant fraud is a combined responsibility of both DMAS and DSS. 2. DSS The responsibilities of DSS are: • the determination of continuing eligibility for Medicaid and FAMIS,

• the referral of individuals with inappropriate MA payments to the DMAS Recipient Audit Unit, and

• the referral of certain individuals to the Health Insurance Marketplace.

3. DSS/Cover Virginia Certain processes are handled at DSS or at Cover Virginia, with general responsibilities that may include:

• the determination of initial eligibility for Medicaid and FAMIS, including applications referred from the Health Insurance Marketplace,

• the enrollment of eligible persons in the Medicaid or FAMIS programs,

• the maintenance of case records pertaining to the eligibility of MA enrollees for certain populations or aid categories.