Virginia Medicaid entered 2026 following one of the most significant restructuring events in the state’s managed care history. Effective July 1, 2025, the Virginia Department of Medical Assistance Services (DMAS) implemented a new Cardinal Care Managed Care contract that brought major changes to every provider in the Virginia Medicaid network. Molina Healthcare exited the Cardinal Care program, with its members transitioning to the newly entering Humana Healthy Horizons in Virginia. The Foster Care Specialty Plan was formalized under Anthem HealthKeepers Plus as the statewide administrator. And critically for providers, DMAS eliminated the historical 90-day grace period after license expiration — meaning any provider whose license lapses is immediately barred from Medicaid billing until reactivation.

For Virginia providers, 2026 is a year of operational compliance verification. Every enrollment record in the DMAS PRSS system must be current and accurate. Every provider whose license recently renewed must confirm PRSS records are updated. And every practice that served former Molina members must verify those patients’ current Humana enrollment before submitting any 2026 claims.

Virginia Medicaid covers approximately 1.3 million Virginians — about 15% of the state’s population — through its Cardinal Care managed care program. This guide covers the complete Virginia billing and credentialing framework for 2026.

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Part 1: Cardinal Care — Virginia’s Unified Medicaid Program

How Virginia Medicaid Is Structured

Virginia Medicaid is administered by the Department of Medical Assistance Services (DMAS) at dmas.virginia.gov. In October 2023, Virginia consolidated its two prior managed care programs — Medallion 4.0 (standard managed care) and Commonwealth Coordinated Care Plus (CCC Plus) (for individuals needing LTSS) — into a single unified program called Cardinal Care Managed Care (CCMC).

What Cardinal Care covers: All Medicaid managed care services previously covered under Medallion 4.0 and CCC Plus, including physical health, behavioral health, long-term services and supports, nursing facility care, and HCBS waiver services — all through a single MCO.

Coverage for dual-eligible members: Dual-eligible Virginia Medicaid members (Medicare + Medicaid) are also enrolled in Cardinal Care. The MCO coordinates both Medicare and Medicaid benefits, though Medicare remains primary for covered services.

The Five Active Cardinal Care MCOs in 2026

MCO	Phone	Notes
Aetna Better Health of Virginia	800-279-1878	Active Cardinal Care MCO
Anthem HealthKeepers Plus	800-901-0020	Includes Foster Care Specialty Plan statewide
Humana Healthy Horizons in Virginia	800-444-9137	NEW July 1, 2025 — replaced Molina
Sentara Community Plan	800-353-2229	Virginia-based regional MCO
UnitedHealthcare Community Plan of Virginia	800-279-4149	Statewide presence

⚠️ Molina Healthcare is no longer active in Virginia Cardinal Care as of July 1, 2025. Any claims submitted to Molina payer IDs after this date will be denied. Former Molina members were auto-enrolled in Humana if they did not actively select another plan by September 30, 2025. Verify every former Molina patient’s current MCO enrollment before submitting any claims.

Foster Care Specialty Plan — Anthem HealthKeepers Plus

Effective July 1, 2025, all youth who qualify for Foster Care Medicaid are enrolled in Anthem HealthKeepers Plus for the Foster Care Specialty Plan (FCSP) — statewide, regardless of geographic region. This means:

• Foster care youth who were previously enrolled with other MCOs for standard Medicaid were moved to Anthem HealthKeepers Plus FCSP
• Providers serving foster care youth must confirm Anthem HealthKeepers Plus FCSP enrollment
• Claims for FCSP members route to Anthem HealthKeepers Plus, not the member’s prior MCO

FAMIS — Virginia’s CHIP Program

The Family Access to Medical Insurance Security (FAMIS) program is Virginia’s CHIP program for uninsured children in families with incomes too high for Medicaid. FAMIS members are now also part of the Cardinal Care framework and can make plan choices through the Cardinal Care managed care enrollment system.

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Part 2: The Two-Step Virginia Medicaid Enrollment System

Virginia Medicaid provider enrollment is a two-step sequential process. Both steps must be completed before submitting claims to any Cardinal Care MCO.

Step 1 — DMAS PRSS Enrollment

PRSS (Provider Services Solution) is DMAS’s provider enrollment portal. All Virginia Medicaid providers must enroll through PRSS before any Cardinal Care MCO contracting can proceed.

PRSS Portal: vamedicaid.dmas.virginia.gov DMAS Provider Helpline: 800-552-8627

PRSS enrollment requirements:

• Active NPI
• Valid Virginia state license (no grace period after expiration — see 2026 updates)
• Provider type and specialty matching services billed
• All service locations separately enrolled with their own location-specific information
• $750 institutional provider enrollment fee (per location, 2026)

PRSS processing time: 30–60 days for clean applications. Record the Application Tracking Number (ATN) after submission.

⚠️ License grace period eliminated July 1, 2025: DMAS formally eliminated the historical 90-day grace period that previously allowed providers to continue billing Medicaid for 90 days after license expiration. Effective July 2025, any license expiration immediately results in eligibility to bill Medicaid being suspended until the license is renewed and PRSS records are updated. Build license renewal reminders at minimum 90 days before expiration.

Step 2 — Cardinal Care MCO Contracting

After PRSS approval, providers must contract separately with each Cardinal Care MCO they want to participate with. PRSS enrollment does not automatically contract you with any MCO.

Process for each MCO:

1. Confirm CAQH ProView profile is current — all five Virginia MCOs use CAQH
2. Contact each MCO’s provider relations department
3. Complete MCO credentialing review (60–90 days per plan)
4. Sign participating provider agreement
5. Confirm network activation effective date before submitting first claim

Critical note on Anthem BCBS Virginia’s three separate tracks: Anthem operates three separate product lines in Virginia requiring three separate enrollment workflows:

• Anthem BCBS Virginia commercial — through Availity
• Anthem HealthKeepers Plus (Medicaid Cardinal Care) — through DMAS PRSS + separate MCO contracting
• Anthem HealthKeepers Medicare Advantage — requires PECOS Medicare enrollment as prerequisite

Completing Anthem commercial credentialing does NOT satisfy HealthKeepers Plus Medicaid credentialing. They are entirely separate processes.

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Part 3: Eligibility Verification in Virginia

Virginia Medicaid Eligibility Verification Options:

ARS (Automated Response System): Real-time eligibility verification available 24/7 MediCall: Telephonic eligibility system — 1-800-772-9996 or 1-800-884-9730 (24/7) DMAS Web Portal: vamedicaid.dmas.virginia.gov for provider eligibility queries 270/271 EDI: Standard electronic eligibility transactions

Key verification rules:

• Verify MCO enrollment at every visit — members can change plans during open enrollment periods (first 90 days after enrollment, then annually by region)
• For foster care youth — confirm Anthem HealthKeepers Plus FCSP enrollment specifically
• For former Molina members — verify current Humana enrollment or new plan selection
• Dual-eligible members — confirm Cardinal Care MCO enrollment and identify Medicare as primary

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Part 4: 2026 Key Updates Every Virginia Provider Needs to Know

1. New Cardinal Care Contract — July 1, 2025

The new Cardinal Care Managed Care contract took effect July 1, 2025 and is the governing contract for all 2026 Cardinal Care billing. Key operational changes under the new contract:

• Molina exited; Humana entered
• Foster Care Specialty Plan centralized under Anthem HealthKeepers Plus statewide
• FAMIS members integrated into Cardinal Care enrollment system

2. License Grace Period Eliminated

The 90-day grace period after provider license expiration was eliminated July 1, 2025. Any lapsed license results in immediate ineligibility to bill Medicaid (FFS and all MCOs). Track license renewal dates meticulously and begin renewal 90 days before expiration.

3. Molina → Humana Member Transition

Former Molina members who did not actively select a new plan by September 30, 2025 were auto-enrolled in Humana Healthy Horizons in Virginia. By 2026, all former Molina patients should be in their new plan. However:

• Verify every patient who was previously on Molina — confirm current enrollment in your system
• Confirm your practice has a contract with Humana Healthy Horizons if you serve these patients

4. DMAS PRSS Enrollment — Current Records Required for All Service Locations

DMAS explicitly requires enrollment to be current and active for all service locations and all provider types. DMAS and all Cardinal Care MCOs are prohibited from paying claims to network providers who are not properly enrolled in PRSS for the specific service location and provider type matching the billed services.

Any address change, ownership change, new practice location, or provider type change must be updated in PRSS promptly. Outdated PRSS records trigger claim denials even when the provider is otherwise in good standing.

5. Virginia Rural Health Transformation Initiative

DMAS is implementing a Rural Health Transformation initiative improving health care access in rural Virginia communities. Providers in rural Virginia should monitor DMAS announcements for rural-specific Medicaid billing changes, enhanced rates, or expanded service coverage under this initiative.

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Part 5: Claim Filing Limits in Virginia

⚠️ Important: Your specific provider contract governs your actual filing deadline. Always verify in your signed agreement with each payer.

Virginia Medicaid and MCO Timely Filing

Payer	Timely Filing Limit	Notes
Virginia Medicaid FFS (DMAS)	12 months from date of service	FFS population not in managed care
Aetna Better Health of Virginia	180 days from date of service	Verify with your contract
Anthem HealthKeepers Plus	180 days from date of service	Verify with your contract
Humana Healthy Horizons Virginia	90–180 days from date of service	New plan — verify with contract
Sentara Community Plan	180 days from date of service	Verify with your contract
UnitedHealthcare Community Plan	90–180 days from date of service	Varies by contract

Commercial and Medicare Timely Filing

Payer	Timely Filing Limit	Notes
Medicare Part A/B (Palmetto GBA, J11)	12 months from date of service	Palmetto GBA is Virginia’s Medicare MAC
Medicare Advantage	90–120 days from date of service	MA plans set own deadlines
Anthem BCBS Virginia (commercial)	180 days from date of service	Dominant commercial carrier
Optima Health (Sentara)	180 days from date of service	Virginia-based regional carrier
CareFirst BlueCross BlueShield	180 days from date of service	Northern Virginia / DC metro
UnitedHealthcare (commercial)	90–180 days from date of service	Varies by employer contract
Aetna (commercial)	120 days from date of service	Verify with contract
Kaiser Permanente Mid-Atlantic	90–180 days from date of service	Northern Virginia
Humana	90 days from date of service	Shortest window

Virginia Medicare MAC: Virginia’s Medicare Administrative Contractor is Palmetto GBA, covering Jurisdiction 11 (J11) — Virginia, West Virginia, North Carolina, South Carolina, and Tennessee. For Medicare billing resources, Virginia providers should use Palmetto GBA at palmettogba.com.

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Part 6: Commercial Payer Landscape in Virginia

Virginia’s commercial insurance market reflects the state’s geographic diversity — from the Northern Virginia/DC metro with its high-income federal employee and technology sector workforce to rural southwestern Virginia with a predominantly locally-insured population.

Anthem Blue Cross and Blue Shield of Virginia is the dominant commercial carrier statewide. Anthem also operates as a Cardinal Care MCO (Anthem HealthKeepers Plus), Medicare Advantage plan, and the Foster Care Specialty Plan administrator — giving it one of the broadest presences of any payer in the Virginia market.

Optima Health (Sentara Health) is Virginia’s major regional commercial carrier, affiliated with Sentara Health system. Sentara Community Plan participates in Cardinal Care as an MCO. Optima Health has strong commercial market share particularly in Hampton Roads (Norfolk, Virginia Beach, Chesapeake) and other Sentara-affiliated markets.

CareFirst BlueCross BlueShield serves Northern Virginia and the DC metro corridor. For practices in Fairfax, Arlington, Alexandria, and the greater DC metro area, CareFirst is a significant commercial payer alongside Anthem.

Kaiser Permanente Mid-Atlantic operates a significant HMO presence in Northern Virginia with vertically integrated care delivery. Kaiser members receive care exclusively from Kaiser providers — contracting with Kaiser is a separate process from other commercial payers.

Other major commercial payers:

• UnitedHealthcare — significant employer group presence statewide
• Aetna — commercial presence for large employer groups
• Cigna — commercial presence in metropolitan areas
• Humana — growing commercial and strong Medicare Advantage presence

Regional market notes:

• Northern Virginia (Fairfax, Arlington): Anthem BCBS, CareFirst, Kaiser Permanente dominant; large federal employee FEHB plans significant
• Richmond (Henrico, Chesterfield): Anthem BCBS dominant; UnitedHealthcare and Aetna significant
• Hampton Roads (Norfolk, Virginia Beach): Optima Health/Sentara particularly strong; Anthem BCBS significant
• Roanoke/Southwest Virginia: Anthem BCBS dominant; smaller regional carriers; Medicaid significant portion of payer mix

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Part 7: Commercial Billing Laws and State Mandates

Virginia HB 822 — Prior Authorization Step Therapy Reform

Virginia House Bill 822 (effective 2022, enforcement active 2026) addresses step therapy and prior authorization requirements for commercial payers. Key provisions:

• Commercial plans must allow exceptions to step therapy requirements when the required first-line drug is contraindicated or has been tried and failed
• Exception requests must be submitted and processed on defined timelines
• Virginia providers experiencing systematic step therapy denials without appropriate exception processes should document and escalate to the Virginia Bureau of Insurance

Virginia Surprise Billing Protections

Virginia aligns with the federal No Surprises Act. The Virginia State Corporation Commission (SCC) oversees insurance compliance. Virginia providers billing surprise billing-eligible services must provide good faith cost estimates to uninsured and self-pay patients and comply with the federal IDR (Independent Dispute Resolution) process for out-of-network payment disputes.

Virginia Mental Health Parity

Virginia enforces federal MHPAEA requirements for group health plans. The Bureau of Insurance handles parity complaints. Virginia providers experiencing systematic behavioral health denial patterns that differ from equivalent physical health service authorization should document the comparative denial data and file a Bureau of Insurance complaint to trigger parity review.

Virginia Workers’ Compensation

Virginia operates a private carrier workers’ compensation system — employers purchase WC coverage from private insurance carriers, not a state fund. The Virginia Workers’ Compensation Commission (VWC) administers the WC system.

Virginia WC key provisions:

• All employers with 3 or more regular employees must carry workers’ compensation
• Injured workers must receive medical care from a panel of at least three physicians selected by the employer
• The injured worker selects their treating physician from the employer’s panel
• Authorization requirements vary by carrier — confirm with the specific WC carrier before rendering non-emergency services
• Medical fee schedule: Virginia uses a WC medical fee schedule published by the Virginia Workers’ Compensation Commission

WC provider authorization: Contact the employer’s WC insurance carrier for authorization. In emergency cases, treatment begins immediately; authorization is obtained post-service for the emergency component.

Virginia WC billing: Bill the employer’s WC insurance carrier using CMS-1500 with WC-specific billing codes and the claim number obtained from the employer or carrier. Do not bill the patient’s health insurance for work-related injuries covered by WC.

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Part 8: Credentialing in Virginia

Step 1 — DMAS PRSS Enrollment

Portal: vamedicaid.dmas.virginia.gov Helpline: 800-552-8627

Requirements: Active NPI, Virginia state license (immediately suspended upon expiration), provider type matching services billed, all service locations enrolled. Processing: 30–60 days for clean applications. $750 fee for institutional providers per location.

Step 2 — Cardinal Care MCO Contracting (5 Separate Processes)

After PRSS approval, contract with each MCO:

• CAQH ProView required by all five MCOs — re-attest every 120 days
• 60–90 days per MCO for contracting and credentialing
• Anthem HealthKeepers Plus and Anthem commercial are separate credentialing tracks

Virginia State Licensing

Provider Type	Board
Physicians (MD/DO)	Virginia Board of Medicine — dhp.virginia.gov
Nurse Practitioners	Virginia Board of Nursing — dhp.virginia.gov
Physician Assistants	Virginia Board of Medicine
All licensed providers	Virginia Department of Health Professions (DHP) — dhp.virginia.gov

Virginia physician licenses renew on a biennial cycle by last name initial. No grace period after expiration in Medicaid — renew proactively.

Virginia Credentialing Timeline

Payer / Enrollment	Typical Timeline
DMAS PRSS enrollment	30–60 days
Cardinal Care MCO (each)	60–90 days after PRSS
Anthem BCBS Virginia (commercial)	60–90 days
Optima Health (commercial)	60–90 days
CareFirst (Northern VA)	60–90 days
UnitedHealthcare / Aetna	90–120 days
Medicare PECOS (Palmetto GBA J11)	60–90 days

Plan at least 120–150 days before first patient care for new Virginia providers requiring full Cardinal Care MCO participation.

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What Virginia Providers Should Do Right Now

For Cardinal Care and Molina transition:

• Verify every former Molina patient’s current MCO enrollment — confirm Humana Healthy Horizons or alternate selection
• Confirm your practice has active Humana Healthy Horizons contracting if you serve former Molina patients
• Confirm foster care youth patients are verified under Anthem HealthKeepers Plus FCSP

For PRSS enrollment compliance:

• Audit every provider’s Virginia state license renewal date — build 90-day advance renewal reminders
• Confirm PRSS records reflect current address, provider types, and all active service locations
• Any changes since last PRSS update must be submitted immediately

For commercial billing:

• Prioritize Anthem BCBS Virginia credentialing as three separate tracks (commercial, HealthKeepers Plus, HealthKeepers Medicare Advantage)
• For Hampton Roads practices — Optima Health/Sentara credentialing is a high priority
• For Northern Virginia practices — CareFirst and Kaiser credentialing are essential
• Document any commercial prior authorization denials for step therapy to support HB 822 exception requests

For workers’ compensation:

• Identify the specific WC carrier for each injured worker before billing
• Obtain the claim number and adjustor contact before rendering non-emergency services
• Bill using the Virginia WC fee schedule rates, not standard commercial rates

At ClaimsXperts, we work with Virginia providers on DMAS PRSS enrollment, Cardinal Care MCO credentialing, Humana transition, and full-cycle revenue cycle management.

Contact us today at https://www.rcmmasters.com/#contactus

ClaimsXperts is a Revenue Cycle Management company based in Frisco, TX.