Virginia Billing Reference

Medical Billing in Virginia: Payer Landscape, Medicaid & Timely Filing

Virginia expanded Medicaid in 2019 under the Medicaid Innovation Act, adding 400,000+ enrollees almost overnight. Plans include Aetna Better Health, Anthem HealthKeepers Plus, Molina, and Virginia Premier. The rapid expansion created credentialing backlogs that many practices are still working through. Timely filing is 12 months for most payers.

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Medical Billing in Virginia: The Short Version

Virginia consolidated its Medicaid managed care programs (formerly Medallion 4.0 and CCC Plus) into Cardinal Care, with five statewide health plans. The commercial market splits geographically: CareFirst BCBS dominates Northern Virginia's DC-metro corridor, Anthem covers the rest of the state, and Sentara Health Plans anchors Hampton Roads. The federal workforce adds heavy FEP and TRICARE volume unmatched in most states.

Payer Landscape

Major Payers in Virginia

Payer	Type	What Billing Teams Should Know
Anthem BCBS of Virginia	Commercial / Blue plan	Statewide Blue outside the DC metro
CareFirst BCBS	Commercial / Blue plan	Northern Virginia / DC metro Blue; separate contract from Anthem
Sentara Health Plans	Provider-owned	Hampton Roads integrated system payer (formerly Optima)
UnitedHealthcare / Aetna / Cigna	Commercial	Federal-contractor employer books in NoVA
BCBS FEP	Federal Employee Program	Separate enrollment from commercial Blue networks
TRICARE East (Humana Military)	Military	Separate credentialing and claims system
Virginia Medicaid (DMAS)	Medicaid	Cardinal Care plans carry most volume

Medicaid Structure

Virginia Medicaid (Cardinal Care): Managed Care Plans

Administered by the Department of Medical Assistance Services (DMAS). The patient's plan assignment — not just Medicaid eligibility — determines the portal, prior-auth list, and filing rules that apply.

Plan	Notes
Anthem HealthKeepers Plus	Largest Cardinal Care plan
Sentara Community Plan	Formerly Optima; Hampton Roads strength
Aetna Better Health of Virginia	Statewide Cardinal Care plan
Molina Complete Care	Statewide Cardinal Care plan
UnitedHealthcare Community Plan	Statewide Cardinal Care plan

Filing Deadlines

Timely Filing Limits for Virginia Claims

Initial-claim windows for the payers Virginia practices bill most. Commercial limits are contract-specific — always confirm against your provider agreement and the payer's current manual.

Payer	Timely Filing Limit	Notes
Virginia Medicaid (Cardinal Care)	365 days from date of service	MCO contract windows may be shorter — commonly 180 days
Medicare (original)	12 months from date of service	Set by federal law; no contract variation
UnitedHealthcare (commercial)	90 days from date of service	Contract-specific; some plans allow 180
Aetna (commercial)	120 days from date of service	Contract-specific; verify provider agreement
Cigna (commercial)	90 days from date of service	Contract-specific; verify provider agreement
Humana (commercial)	90 days from date of service	Among the strictest; Medicare Advantage differs

Verified against payer publications at time of writing (July 2026). Filing limits change by contract and plan year — treat this table as a starting point, not a substitute for the payer manual. See our methodology.

VA-Specific Rules

Virginia Billing Realities to Know

Cardinal Care Consolidation

Medallion 4.0 and CCC Plus merged into Cardinal Care — older references to Medallion program rules may be outdated; DMAS bulletins control.

Two Blues by Geography

CareFirst (NoVA) and Anthem (rest of state) split Virginia. DC-metro practices often hold both contracts plus FEP.

Federal Workforce Volume

FEP and TRICARE require separate enrollment and follow their own rules — they are not ordinary commercial claims wearing federal badges.

Sentara Dual Role

Sentara is both dominant health system and major payer in Hampton Roads; network decisions carry system-competition implications.

Frequently Asked Questions

Virginia Medicaid (Cardinal Care) allows 365 days from date of service for initial claims, administered by the Department of Medical Assistance Services (DMAS). Managed care plans operating in Virginia may apply shorter contractual windows, so always verify each plan's provider manual.

Anthem HealthKeepers Plus, Sentara Community Plan, Aetna Better Health of Virginia, Molina Complete Care, UnitedHealthcare Community Plan. Each plan maintains its own provider portal, prior authorization list, and claim submission rules — the patient's plan assignment, not just Medicaid status, determines how a claim must be billed.

Anthem BCBS of Virginia, CareFirst BCBS, Sentara Health Plans, UnitedHealthcare / Aetna / Cigna, BCBS FEP, alongside Medicare and Virginia Medicaid (Cardinal Care). See the payer landscape table on this page for what billing teams should know about each.

Cardinal Care is Virginia’s consolidated Medicaid managed care program, combining the former Medallion 4.0 (families/children) and CCC Plus (complex care) programs under one umbrella with five statewide health plans. Provider enrollment and claims now follow Cardinal Care contracts and DMAS guidance rather than the legacy program rules.

Code Reference

Common Codes Billed in This State

Frequently billed codes in this state’s payer environment, with notes on state-specific rules and common denial patterns.

Code	Description	State-Specific Note
99213	Office visit, est. patient — level 3	Medicaid expansion (2019): verify eligibility for new enrollees
99214	Office visit, est. patient — level 4	Anthem HealthKeepers Plus and Virginia Premier are dominant MCOs
99215	Office visit, est. patient — level 5	Credentialing backlogs from 2019 expansion still affect some practices
Mod. GT	Telehealth — real-time audio/video	Virginia requires telehealth parity; all MCOs allow with auth
G0438	Annual wellness visit — initial	High MA enrollment in Northern Virginia and Richmond metros
CO-50	Non-covered service	Common for providers not yet credentialed post-expansion

Codes and reimbursement rates change annually. Verify current fee schedules with each payer before billing. Full code lookup →