MedicaidAdministrativeMedium impact
Updates to Pharmacy Manual Chapter 7
Virginia Medicaid - DMAS·VA · Pharmacy·Pharmacy
Effective date
Aug 27, 2026
We identified it
Sep 11, 2026
Summary
Virginia Medicaid updated Pharmacy Manual Chapter 7 with revisions to the RetroDUR (Retrospective Drug Utilization Review) process and removed RetroDUR criteria for Nursing Facility members, along with minor grammatical corrections. The memo emphasizes that all providers must maintain current enrollment, contact information, and license information in the PRSS (Provider Services Solution) portal to avoid claim payment disruptions, as federal rules prohibit MCOs and DMAS from paying claims to non-enrolled network providers.
Action Required
By August 27, 2026: (1) All prescribing providers and pharmacists must review the updated RetroDUR process in Pharmacy Manual Chapter 7 and adjust claim submission workflows accordingly. (2) Billing team must verify that all provider enrollment records in PRSS are current, including license information and contact details for all service locations. (3) Providers serving Nursing Facility members should remove RetroDUR criteria checks from billing system rules, as this requirement has been eliminated. (4) Establish a recurring calendar reminder to periodically verify PRSS enrollment status to prevent future claim payment denials. Failure to maintain current PRSS enrollment will result in claim payment denial under federal rules, regardless of MCO or FFS status.