Virginia’s Medicaid managed care program is shifting, and if you’re a healthcare provider in the Commonwealth, you’re likely already feeling the effects. The state’s Medicaid Managed Care expansion is making a move that’s set to connect more residents with essential care and broaden coverage for vulnerable populations.
This is great news for patients and a big win for access to care. But with broader access comes added complexity for providers and billing teams. With the right preparation, your practice can transform these challenges into opportunities to streamline your processes and improve cash flow.
There’s no need to derail your revenue cycle when you have 5 Star Billing as your partner. We’ve guided practices through policy shifts before, and we’re ready to do it again for you with our Virginia medical billing services. Consider this your roadmap to staying ahead, maintaining compliance, and ensuring every claim is paid, regardless of the changes that come.
Let’s Safeguard Your Revenue Cycle
What The Expansion Means for Providers
Virginia officially launched its Cardinal Care Managed Care program, consolidating the state’s previous Medallion 4.0 and Commonwealth Coordinated Care Plus (CCC Plus) programs into one unified system.
This is a major reorganization that brings all Medicaid managed care members under one umbrella program, with the aim of simplifying access for patients. It also reshapes how providers will handle billing and payer relationships going forward.
These changes will bring changes to your Virginia medical billing operations, and here’s why:
| For Primary Care Providers | Many Molina Healthcare members are transitioning to Humana Healthy Horizons, which means updating authorization requirements, care coordination protocols, and billing workflows for existing patients. |
| For Specialists | You’re now working with five Managed Care Organizations (MCOs), each with distinct referral pathways, authorization timelines, and documentation rules. |
| For Behavioral Health Practices | Providers who served Molina members are now recredentialing or contracting with new MCOs, including Humana, to maintain patient continuity. |
| For Hospitals and Health Systems | The five MCOs under Cardinal Care maintain their own payment structures, quality metrics, and utilization criteria—requiring close coordination from your billing and administrative teams. |
New Rules Mean New Complexities
The rollout of Virginia Medicaid Managed Care changes how you bill. Behind the new program structure are evolving payer rules, documentation standards, and timelines that can easily trip up even experienced billing teams.
- New Layers of Authorization
Each MCO has its own rules for prior authorizations, referrals, and care coordination. What was once an automatic approval under fee-for-service Medicaid may now require extra documentation or a new form entirely.
- Timelines Are Tighter
Under managed care, claim submission deadlines can vary across MCOs. Automated claim tracking and prompt follow-ups are critical here since missing even one can lead to delays in reimbursement or denials.
- Documentation Demands Are Rising
More payers mean more sets of documentation requirements. Be cautious for any minor mistakes or inconsistencies, as these can already be enough to trigger a claim for review.
- Shifting Reimbursement Patterns
Unlike traditional Medicaid, managed care rates are negotiated by each MCO. Knowing the difference of each rate (and tracking reimbursement trends) can help identify where your practice might be underpaid or where certain payers routinely lag in payments.
- Eligibility and System Hiccups
Patients might still appear under their old plan in some systems, or eligibility checks might show conflicting information. Verifying eligibility in real-time before every visit helps prevent claim rejections and rebilling issues later on.
- Staying Ahead of Constant Change
Each MCO periodically updates its billing guidelines, and those updates don’t always get loud announcements. Designate a team member or a trusted billing partner to regularly monitor those changes.
How to Adapt Your Revenue Cycle to the Expansion
The changes can be complex, but they are not unsolvable. It’s simply a matter of tightening systems and strengthening coordination.
- Start with a Medicaid Workflow Audit
Before you adjust anything, know where you stand. Review how your team currently handles:
- Eligibility checks: Are you verifying Medicaid coverage at every visit and capturing updated plan info?
- Coding accuracy: Do your CPT and diagnosis codes align with current payer requirements?
- Documentation: Are provider notes and billing codes telling the same story?
A quick internal audit can reveal small process gaps before they turn into big reimbursement problems.
- Update Your Billing Software and Clearinghouse Settings
Make sure your systems are ready for the new MCO structure by:
- Adding the five Cardinal Care MCOs to your clearinghouse list.
- Updating payer IDs, fee schedules, and EDI connections.
- Running test claims to confirm that everything routes properly.
Even one outdated payer setup can trigger claim rejections and slow down payments you’ve already earned.
- Train and Empower Your Team
Your team needs to know how to appeal denials with each MCO and recognize patterns in the reasons for denials. So, make sure they’re up to speed on:
- Which procedures require prior authorizations with each MCO.
- Where to submit authorization requests (portal, phone, fax).
- Average turnaround times.
- What documentation each MCO require upfront.
A quick training refresh can save hours of back-and-forth with payers later on.
- Lock in Real-Time Eligibility and Payer Updates
The biggest billing nightmares start with outdated information. Implement real-time eligibility checks if you’re not doing them already. Alternatively, you can assign payer policy monitoring to a specific team member and include it in their weekly responsibilities.
- Build Your Billing-Clinical Communication Loop
Create a feedback loop where your billing team shares denial trends with clinicians, and clinicians understand how their documentation impacts reimbursement.
- Keep a Close Eye on Policy Updates
Each MCO may roll out updates in waves. Assign one team member or have a trusted billing partner to track changes to authorization lists, billing codes, and submission guidelines.
Get 5 Star Billing as Your Partner in Medicaid Revenue Optimization
If all these new rules, forms, and payer updates have got you confused, that’s understandable. It’s hard not to be, even if you are a seasoned practitioner.
When it gets overwhelming fast and it’s hard to keep up, always know that you can rely on the experts at 5 Star Billing. We’ve guided providers through numerous Medicaid transitions, and we’re honored to do the same for you with our Virginia healthcare billing services.
We integrate seamlessly with your practice, serving as an extension of your team while our expert medical billers:
- Reduce denials by identifying and resolving authorization and documentation issues before submission.
- Track claims in real time, so you know where every dollar stands.
- Identify reimbursement gaps and ensure your payments align with contract terms.
- Stay ahead of payer updates, adjusting workflows the moment new rules take effect.
The managed care landscape will keep shifting. Policies will change. MCOs will update their requirements. But we got it covered for you.
If your practice is handling Virginia’s Medicaid changes and you’re struggling with it, give us a call. Let’s make sure your revenue remains steady, regardless of the changes you face along the way.
Stay Compliant. Stay Profitable.
Frequently Asked Questions
How will the Medicaid Managed Care expansion in Virginia affect the reimbursement timing?
During the transition, reimbursement timelines may vary as MCOs adjust their internal systems. Some providers may experience short-term delays or claim reprocessing. Staying on top of claims submissions and maintaining real-time reporting will help identify and resolve payment issues faster.
How long will the transition period last for providers?
The transition is expected to continue through 2025, as member assignments, credentialing, and system updates are finalized. Providers should expect ongoing updates from DMAS and each MSO, particularly regarding authorizations and billing requirements.
What should providers do if patients are unsure which Medicaid plan they’re enrolled in?
Encourage patients to confirm their plan through Cover Virginia or by calling the Managed Care Helpline (1-800-643-2273). This ensures accurate eligibility checks and prevents billing under the wrong payer, which is a common cause of claim denials during transitions.
If I outsource Medicaid billing in Virginia, is it a good idea?
Yes, especially if your team is already stretched thin. Working with a dedicated billing partner like 5 Star Billing ensures that credentialing, claim submissions, and denial management stay consistent during system changes. It’s a smart way to protect cash flow and reduce administrative pressure while things stabilize.