[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-310574-105":3,"detail-sidebar-cat-1-en-105":74,"doc-detail-310574-en":120},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":67,"head_meta":69,"extra_data":71,"updated_unix":73},105,"en","virginia-qualified-entity-agreement-for-hospital-presumptive-eligibility-responsibilities-and-agreement","Virginia Qualified Entity Agreement for Hospital Presumptive Eligibility - Responsibilities and Agreement","","Virginia Medicaid provider agreement for hospitals seeking Qualified Entity status to conduct Hospital Presumptive Eligibility (HPE) determinations. The agreement outlines responsibilities including staff HPE training, offering HPE to eligible patients with immediate medical need, income screening using HPE forms, ensuring determiners are direct employees, accurate determinations, timely enrollment form submission, and patient notification plus Medicaid application guidance. It also sets performance standards, potential training or disqualification processes, nondiscrimination obligations, and administrative authority to revoke, suspend, or deny HPE authorization, with termination and notice requirements.",{"@graph":14,"@context":66},[15,34,49],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/letters/","Letters",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/virginia-qualified-entity-agreement-for-hospital-presumptive-eligibility-responsibilities-and-agreement/310574/",4,{"url":32,"name":10,"@type":35,"author":36,"headline":10,"publisher":39,"fileFormat":42,"inLanguage":8,"description":12,"dateModified":43,"datePublished":43,"encodingFormat":42,"isAccessibleForFree":44,"interactionStatistic":45},"DigitalDocument",{"name":37,"@type":38},"Aran","Person",{"url":19,"name":40,"@type":41},"DocShare","Organization","application/pdf","2026-09-20",true,{"@type":46,"interactionType":47,"userInteractionCount":4},"InteractionCounter",{"@type":48},"ViewAction",{"@type":50,"mainEntity":51},"FAQPage",[52,58,62],{"name":53,"@type":54,"acceptedAnswer":55},"Who must participate to become an HPE Qualified Entity in Virginia?","Question",{"text":56,"@type":57},"The agreement requires hospitals to participate as Virginia Medicaid providers to perform Hospital Presumptive Eligibility determinations.","Answer",{"name":59,"@type":54,"acceptedAnswer":60},"What responsibilities must the hospital fulfill when conducting HPE determinations?",{"text":61,"@type":57},"The hospital must train staff before they begin, offer the HPE program to qualified patients with immediate need, screen for income eligibility using HPE forms, ensure determiners are direct employees, accurately determine eligibility, and notify patients of outcomes.",{"name":63,"@type":54,"acceptedAnswer":64},"How are performance standards and possible disqualification handled?",{"text":65,"@type":57},"DMAS collects and analyzes performance data, including full Medicaid application submission and Medicaid eligibility outcomes. If standards are not met, DMAS may require additional training under a 60-day improvement plan, and disqualification can occur if performance does not improve.","https://schema.org",{"og:url":32,"og:type":68,"og:title":10,"og:site_name":40,"og:description":12},"article",{"robots":70,"canonical":32},"index,follow",{"doc_id":72,"site_id":7},310574,1789884068,{"code":4,"msg":75,"data":76},"success",[77,82,87,92,97,102,107,111,116],{"id":78,"doc_module":22,"doc_module_name":25,"category_name":79,"show_sort_weight":80,"slug":81},11,"Presentations",90,"presentations",{"id":83,"doc_module":22,"doc_module_name":25,"category_name":84,"show_sort_weight":85,"slug":86},12,"Resumes",80,"resumes",{"id":88,"doc_module":22,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},14,"Invoices",70,"invoices",{"id":93,"doc_module":22,"doc_module_name":25,"category_name":94,"show_sort_weight":95,"slug":96},15,"Posters",60,"posters",{"id":98,"doc_module":22,"doc_module_name":25,"category_name":99,"show_sort_weight":100,"slug":101},16,"Social Media",50,"social-media",{"id":103,"doc_module":22,"doc_module_name":25,"category_name":104,"show_sort_weight":105,"slug":106},17,"Forms",40,"forms",{"id":108,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":109,"slug":110},18,30,"letters",{"id":112,"doc_module":22,"doc_module_name":25,"category_name":113,"show_sort_weight":114,"slug":115},21,"Paper Templates",5,"papers-templates",{"id":117,"doc_module":22,"doc_module_name":25,"category_name":118,"show_sort_weight":4,"slug":119},158,"General","general-158",{"code":4,"msg":75,"data":121},{"doc_id":72,"user_id":122,"nickname":37,"user_avatar":123,"doc_module":22,"category_id":108,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":124,"file_id":125,"file_url":126,"file_type":127,"file_size":128,"view_count":4,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":129,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":130,"faqs":131,"seo_title":132,"seo_description":12,"update_tm":73,"read_time":22},137455076865,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Virginia Qualified Entity Agreement for Hospital Presumptive Eligibility  \nThis is an agreement to become a Qualified Entity for Hospital Presumptive Eligibility (HPE) for the purposes of conducting Presumptive Eligibility determinations. You must participate as a Virginia Medicaid provider to perform Hospital Presumptive Eligibility determinations. Please complete, sign, and return this agreement to the Virginia Department of Medical Assistance Services (DMAS) at the contact below:  \nEmail: [HPE@dmas.virginia.gov](HPE@dmas.virginia.gov)  \nMail: Hospital Presumptive Eligibility Agreement  \nMaternal and Child Health  \nDept. of Medical Assistance Services  \n600 East Broad Street, Suite 1300  \nRichmond, VA 23219  \nFax: (804) 612-0043  \nIf you have questions about this application or the Hospital Presumptive Eligibility program, contact DMAS at: (804) [225-4279 or](225-4279 or HPE@dmas.virginia.gov)[ ](225-4279 or HPE@dmas.virginia.gov)[HPE@dmas.virginia.gov](225-4279 or HPE@dmas.virginia.gov).  \nName of hospital  \n\n| Other name (if any used for prov ider serv ices) |  |  | National Prov ider Identif ier number (NPI) |\n| --- | --- | --- | --- |\n| Telephone number ( ) | FAX number ( ) |  |  |\n| Mailing address (no P. O. Box) for Site |  | City , State, Zip |  |\n\nPrimary HPE Contact Person  \n\n| Telephone number ( ) | FAX number\u003Cbr>( ) |\n| --- | --- |\n\nEmail Address  \nHospital Presumptive Eligibility (HPE) Qualified Entity Responsibilities and Agreement  \nI understand that the responsibilities as a n HPE Qualified Entity include:  \n1. Providing the Department of Medical Assistance Services (DMAS) HPE training to all hospital staff members who will perform HPE determinations before they begin conducting them .  \n2. Offering the HPE program to patients who have an immediate medical need and are without current, confirmed Medicaid or FAMIS coverage;  \n3. Screening interested patients for income eligibility using HPE forms and guidelines;  \n4. Ensuring that all individuals performing HPE determinations are direct employees of the hospital and do not work as contractors or vendors of the hospital;  \n5. Accurately determining HPE;  \n6. Submitting completed HPE enrollment forms with the required information on those patients eligible for HPE to the DMAS designee within five (5) calendar days;  \n7. Providing in writing (and orally if appropriate), notification to the patient about the outcome of the HPE determination;  \n8. Informing patients at the time of the HPE determination that they must file a Medicaid application in order to obtain regular Medicaid coverage beyond the HPE period , including information regarding all ways to apply and providing to the individual a Medicaid application form ;  \n9. Informing patients that they may file a Medicaid application regardless of eligibility for HPE;  \n10. Facilitating patients with the completion of an application for Medicaid;  \n11. Keeping current with changes affecting HPE through provider memos , manuals, bulletins, notices, and/or further training;  \n12. Maintaining criteria to continue participation as a n HPE provider based on the expectation of meeting the following standards: (1) the proportion of individuals determined presumptively eligible by the hospital who submit a full application; and  \n(2) the proportion of individuals who are determined eligible for Medicaid based on the full application. The state may disqualify an HPE provider if (1) less than 85% of PE submissions result in a f ull Medicaid application; or (2) less than 70% of individuals are determined eligible for Medicaid based on a full application. For the initial six (6) month period of HPE (January 2014-June 2014), DMAS will collect and analyze performance standard data from all HPE providers. These standards will be assessed and may be revised by DMAS based on the results .  \n13. Participating in additional training by DMAS or other corrective action measures if the HPE provider does not meet the established standa","cbCaihNmxNMGoylQ","https://ap.wps.com/l/cbCaihNmxNMGoylQ","pdf",156102,"English","# Hospital Presumptive Eligibility (HPE) Agreement\n## Mailing and contact information\n## Hospital identification and primary HPE contact\n## Qualified Entity responsibilities and agreement\n## Signature, authorized agent title, and date","[{\"question\":\"Who must participate to become an HPE Qualified Entity in Virginia?\",\"answer\":\"The agreement requires hospitals to participate as Virginia Medicaid providers to perform Hospital Presumptive Eligibility determinations.\"},{\"question\":\"What responsibilities must the hospital fulfill when conducting HPE determinations?\",\"answer\":\"The hospital must train staff before they begin, offer the HPE program to qualified patients with immediate need, screen for income eligibility using HPE forms, ensure determiners are direct employees, accurately determine eligibility, and notify patients of outcomes.\"},{\"question\":\"How are performance standards and possible disqualification handled?\",\"answer\":\"DMAS collects and analyzes performance data, including full Medicaid application submission and Medicaid eligibility outcomes. If standards are not met, DMAS may require additional training under a 60-day improvement plan, and disqualification can occur if performance does not improve.\"}]","Virginia Qualified Entity Agreement for Hospital Presumptive Eligibility - Responsibilities and Agreement | PDF"]