Medical Billing Services in Virginia
Billing, coding, credentialing and denial management for Virginia practices, with Medicare claims through Palmetto GBA (Jurisdiction JM) and Virginia Medicaid handled by people who know the rules.
Medical billing for Virginia practices
Virginia practices bill a wide mix of payers. Anthem dominates much of the commercial market, Sentara is strong in Hampton Roads, and Northern Virginia practices see CareFirst and federal employee plans. Medicaid, now called Cardinal Care, covers expansion adults and is delivered mostly through five managed care plans. Medicare Part B claims go to Palmetto GBA in Jurisdiction M, except in Arlington County, Fairfax County and the City of Alexandria, where Part B is handled by Novitas Solutions in Jurisdiction L. Southwest Virginia and the Southside region have a high share of Medicaid and Medicare patients.
SFA Solutions works with Virginia practices remotely, from Fairfax and Richmond to Roanoke and the coalfield counties. We verify each patient's Cardinal Care plan before the visit, submit most clean claims within 24 hours, and work MCO denials through the plan's reconsideration and appeal steps.
Virginia at a glance
| Medicare contractor | Palmetto GBA, Jurisdiction JM |
|---|---|
| Medicaid timely filing | 12 months from the date of service for claims submitted to DMAS (12VAC30-95-10), with exceptions for third-party retractions and retroactive eligibility; MCOs set limits in their provider contracts |
| NP practice authority | Restricted |
| Cities we serve | Virginia Beach, Norfolk, Chesapeake, Richmond, Arlington, Newport News, Alexandria, Fairfax, Roanoke, Charlottesville |
What Virginia billing involves
These are the programs and rules our team works with for Virginia claims.
Medicare
Palmetto GBA · JMVirginia Part B claims are processed by Palmetto GBA in Jurisdiction JM. Medicare's filing limit is 12 months from the date of service, and appeals start with a redetermination within 120 days of the initial decision.
Virginia Medicaid
Cardinal Care, Virginia's Medicaid and FAMIS program, administered by the Department of Medical Assistance Services (DMAS)
Portal: DMAS Medicaid Enterprise System (MES) provider portal for enrollment, eligibility and fee-for-service claims
Medicaid managed care
Since July 1, 2025, Cardinal Care Managed Care is served by Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Humana Healthy Horizons of Virginia, Sentara Health Plans and UnitedHealthcare Community Plan. Anthem HealthKeepers Plus also administers the foster care specialty plan.
Timely filing
12 months from the date of service for claims submitted to DMAS (12VAC30-95-10), with exceptions for third-party retractions and retroactive eligibility; MCOs set limits in their provider contracts.
Commercial and Medicare Advantage
Anthem Blue Cross and Blue Shield is the largest commercial carrier statewide, with Sentara Health Plans, Aetna, CareFirst BlueCross BlueShield in Northern Virginia, UnitedHealthcare and Cigna also significant. Humana, UnitedHealthcare and Aetna lead Medicare Advantage.
Prompt pay law
Va. Code Section 38.2-3407.15 requires carriers to pay claims within 40 days of receipt, unless the claim is not clean for a good-faith reason, and requires interest on late payments.
Nurse practitioners
Restricted practiceVirginia NPs practice under a practice agreement with a patient care team physician until they complete the equivalent of three years of full-time clinical experience and receive authorization from the boards to practice without one (Va. Code Section 54.1-2957). Payer credentialing files must reflect whichever status applies, and NPs bill under their own NPI either way.
Credentialing
Virginia Medicaid enrollment is done through the DMAS provider enrollment process, and each Cardinal Care MCO then credentials the provider separately. Anthem, Sentara and most commercial plans pull from CAQH ProView. Practices in Northern Virginia often also need enrollment with Maryland and DC Medicaid for cross-border patients.
Billing challenges Virginia practices face
Cardinal Care plan changes
The Cardinal Care managed care contracts that began July 1, 2025 brought in Humana and changed plan assignments for some members. Practices need current eligibility for every visit, because a claim billed to a former plan will deny.
Northern Virginia cross-border billing
Practices near DC see patients covered by Maryland and DC Medicaid, CareFirst and federal employee plans. Each of these payers has its own enrollment, filing limits and network rules.
Practice agreements for newer NPs
NPs who have not yet reached autonomous practice must have a practice agreement on file, and payers may ask for it during credentialing. Missing or expired paperwork delays the effective date and the first claims.
Our services in Virginia
Medical Billing
Learn moreCredentialing & Payer Enrollment
Learn moreMedical Coding
Learn moreDenial Management
Learn moreA/R Recovery
Learn moreEligibility Verification & Prior Authorization
Learn moreMedical Billing Audit
Learn moreRevenue Cycle Management
Learn moreSpecialties we bill in Virginia
Virginia medical billing questions
What is the timely filing limit for Virginia Medicaid?
DMAS requires providers to submit claims within 12 months from the date of service, with exceptions for third-party payer retractions and retroactive eligibility. Cardinal Care MCOs set their own limits in the provider contract.
Which health plans serve Cardinal Care?
Cardinal Care Managed Care plans are Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Humana Healthy Horizons of Virginia, Sentara Health Plans and UnitedHealthcare Community Plan.
How fast must Virginia insurers pay claims?
Under Va. Code Section 38.2-3407.15, carriers must pay claims within 40 days of receipt unless there is a good-faith reason the claim is not clean. Self-funded ERISA plans are not subject to the state statute.
Who processes Medicare claims in Virginia?
Palmetto GBA is the Medicare A/B MAC for Virginia under Jurisdiction M. For Part B, Arlington County, Fairfax County (including the Cities of Fairfax and Falls Church) and the City of Alexandria are served by Novitas Solutions under Jurisdiction L. Enrollment is filed through PECOS.
Get a free billing audit for your Virginia practice
We will review your recent claims and denials against Virginia payer rules and show you what can be recovered.
Nearby states
Primary sources
- DMAS press release, July 1, 2025 Cardinal Care Managed Care
- 12VAC30-95-10 Time limits for claim submission
- Va. Code Section 38.2-3407.15
- Va. Code Section 54.1-2957, Nurse practitioners
- CMS: A/B MAC Jurisdiction M (Palmetto GBA)
- CMS: A/B MAC Jurisdiction L (Novitas Solutions)
Payer rules change. Last reviewed against the primary sources above on . Confirm current rules with the payer before relying on them.
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