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Virginia

Virginia Behavioral Health Credentialing: Cardinal Care and Commercial Payers

Virginia’s credentialing statute does something almost no other state does. It closes the loophole carriers use to stall you, by deeming your application complete 30 days after it arrives. Then it makes them decide in 60 days and pay you back at the in-network rate for the wait. The thing people get wrong here isn’t the law, though. It’s which Blue plan their address belongs to.

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Virginia payers and timelines

The Virginia rule worth knowing

Deemed complete in 30 days. Decided in 60. Paid within 40 of credentialing.

Va. Code 38.2-3407.10:1 requires a carrier to approve or deny a completed credentialing application from a new provider applicant within 60 days. The middle piece is the one nobody knows about: since January 1, 2024 an application is deemed complete 30 days after the carrier receives it unless the carrier tells you otherwise.

That matters more than the 60 days does. In most states the way a file sits for six months is that nobody ever formally calls it complete, so no clock ever starts. Virginia took that away. The carrier has to affirmatively say what’s missing, inside 30 days, or the clock runs anyway.

Then the money. Claims for services you rendered while the application was pending, submitted according to the carrier’s claims policies, have to be adjudicated and paid no later than 40 days after you’re credentialed and contracted, at the in-network rate you would have received had you already been participating. Read the limits in the same breath, because they’re real: it excludes Medicare Advantage, it doesn’t turn a non-covered service into a covered one, and it’s void if credentialing is denied or no contract is executed. And it doesn’t reach Medicaid. Virginia’s commercial credentialing deadlines have nothing to do with your DMAS enrollment.

Virginia is also an any-willing-provider state. Va. Code 38.2-3407 says a carrier’s terms and conditions for preferred provider participation can’t discriminate unreasonably among providers, and that no provider willing to meet those terms shall be excluded. Optum cites it directly on its Virginia page as the reason it accepts applications the way it does. It doesn’t promise you a spot. It is part of why Virginia behavioral health panels tend to run more open than the states around it.

Credentialed›contracted›loaded›connected›payable

Virginia’s statute reaches the first two boxes and the money behind them. It says nothing about loading, EFT or the directory, which is why we set up remittance alongside credentialing rather than after it. Approved claims that can’t reach your bank account still aren’t revenue.

Two tracks

Cardinal Care folded behavioral health in. The Blue map splits the state in two.

Virginia rebranded its whole Medicaid program in 2023 and changed the plan roster in 2025, so a lot of the advice you’ll find is describing a system that no longer exists.

Cardinal Care

Enroll in PRSS, then contract with each plan.

Cardinal Care is the single brand DMAS put over the entire program in 2023, merging Commonwealth Coordinated Care Plus and Medallion 4.0. Most members sit in Cardinal Care Managed Care, where one plan is responsible for physical health, behavioral health and pharmacy together. A fee-for-service layer remains, paid directly by DMAS.

The roster changed on July 1, 2025A new six-year contract started and Molina left the state on June 30, 2025. Humana received Molina’s members, so a Humana contract carries more weight in Virginia now than the national Humana picture would suggest.

Anthem HealthKeepers PlusAetna Better Health of VirginiaHumana Healthy HorizonsSentara Health PlansUnitedHealthcare Community Plan

PRSS is the gate for managed care tooUnder the 21st Century Cures Act a Cardinal Care plan can’t pay a network provider who isn’t enrolled with DMAS in the right provider type and specialty, so the plans check PRSS before they’ll load a contract. State first, plans second, every time.
No behavioral health vendor, but a service-level gate insteadMagellan of Virginia’s behavioral health services administrator contract ended October 31, 2023. Since November 1, 2023 fee-for-service authorisations go to Acentra Health, formerly Kepro, and claims go to DMAS. What replaced the carve-out is that many Virginia Medicaid behavioral health services are keyed to a specific DBHDS license and a specific taxonomy. So the question isn’t which vendor pays you, it’s whether your enrollment matches the service you intend to bill.
Addiction services have extra steps in front of PRSSDMAS asks for the DBHDS license matching your ASAM level of care, and for Preferred Office-Based Addiction Treatment it wants the ARTS Preferred OBAT attestation, the ARTS OBAT credentialing checklist and an organizational staff roster sent to DMAS first. You get an OBAT recognition letter back, and only then do the documents go to PRSS and to each health plan.
The grace period is goneEffective July 1, 2025 DMAS removed the 90-day window that used to follow a license expiration. A lapse now terminates your enrollment agreement and every Cardinal Care plan contract at the same time, and you’re re-enrolled based on the month you apply, so a lapse costs you retroactive billing. Notices go out at 90, 60 and 30 days.

Commercial

Route 123 decides which Blue plan you need.

Anthem is the Blue licensee for Virginia except the city of Fairfax, the town of Vienna, and the area east of State Route 123. CareFirst holds that corner, plus Alexandria, Arlington County, and the parts of Fairfax and Prince William Counties east of Route 123.

Two licensees inside one stateReaching the full in-state Blue population usually means both. That’s a different thing from needing a contract per state, and one Blue contract still reaches Blue members in other states through BlueCard when you’re licensed there.
Northern Virginia isn’t a Virginia marketIt’s the Washington DC metro market. Employers, plan designs and patients cross the Potomac constantly, so a practice in Arlington, Alexandria or eastern Fairfax usually gets more from CareFirst plus DC and Maryland licensure than from adding another downstate Virginia payer.
The federal workforce, and how you reach itVirginia has one of the largest federal workforces in the country, and those members carry the Blue Cross Blue Shield Federal Employee Program. You reach FEP through your local Blue plan contract, so Anthem for most of the state and CareFirst for the Route 123 corner. There’s no separate FEP contract to chase.
Behavioral health doorsAnthem routes it to Carelon Behavioral Health, renamed from Beacon Health Options on March 1, 2023. UnitedHealthcare routes it to Optum in Provider Express. Cigna routes it to Evernorth. Sentara runs its own behavioral packet. Aetna keeps it in-house on a separate form. CareFirst brought behavioral health in-house from Magellan and runs it through its own portal. Starting on the general medical form is the most expensive mistake available in this state.
No state database, but one dependencyVirginia has no state-designated credentialing database written into statute. In practice CAQH is what every major carrier uses, and Optum’s Virginia page says outright that CAQH participation is required here. Treat it as the single upstream dependency.

Virginia commercial payers

Who’s open, who’s closed, and which one your address belongs to.

The 60-day statutory decision and the deemed-complete rule are the carrier’s obligation. What follows is what each one publishes about its own practice, which is a different thing.

Anthem Blue Cross and Blue Shield

The Blue plan for Virginia, except the Route 123 corner
  • Usually: about 90 to 120 days from a complete application, and faster when CAQH is already clean
  • Behavioral health goes to Carelon. Set your CAQH authorization to Global so Carelon can pull your data
  • Where to apply: Anthem’s digital provider enrollment application sits in Availity Essentials under the Anthem payer space and issues a tracking ID on submission
  • Separate contracts: commercial, HealthKeepers Plus Medicaid and Medicare Advantage each have their own effective dates. Credentialing with one doesn’t put you in the others

Separate door: Carelon Behavioral Health

CareFirst BlueCross BlueShield

The contract Northern Virginia practices forget
  • Service area: Maryland, the District of Columbia, the cities of Alexandria and Fairfax, the town of Vienna, Arlington County, and the parts of Fairfax and Prince William Counties east of Route 123
  • Behavioral health is in-house, brought back from Magellan Healthcare, and authorisations run through the CareFirst provider portal
  • No published turnaround, so the statutory clock is what you have. Confirm at submission
  • Adding to an existing group? Use the Provider Updates and Attestation self-service tool in the portal rather than a new-group application. CareFirst states an application can’t be reviewed until every step is done

Sentara Health Plans

Behavioral health network closed to new applicants
  • Read this before you spend time on it. At this verification Sentara isn’t accepting new behavioral health provider applications. It says the network is full and sufficient across all service locations and specialties, and interested providers go on a waiting list
  • Why it catches people: Sentara is one of the largest behavioral health managed care organizations in Virginia, with over 4,000 behavioral health providers, so a lot of local advice still assumes the panel is open
  • What we do: get you on the list so you’re in line when it reopens, rather than filing into a closed network
  • Also: the former Optima Health and Virginia Premier, now one plan. Its commercial line and its Cardinal Care line are separate contracts, and Sentara wants 30 days notice of any change to your location, group affiliation or departure

Separate door: Sentara Behavioral Health

UnitedHealthcare

Behavioral health goes through Optum
  • The strongest published opening in the state. Optum’s Virginia page says it may be accepting requests from MDs, DOs, PAs and RNs with prescriptive authority in all counties, and states that Virginia is an any-willing-provider state
  • Also listed: child and adolescent work, in-home services and nursing home consultation
  • Usually: 60 to 120 days from a complete application. A CAQH ID is required before you apply, then start in Provider Express under Join Our Network

Separate door: Optum Behavioral Health

Aetna

Behavioral health in-house, on its own form
  • Sequence: request for participation, an answer on network need in about 45 days, then credentialing pulled from CAQH, then contracting. Commonly 60 to 120 days end to end
  • Path: behavioral professionals use the separate behavioral health request for participation, including those joining a medical group
  • Separate line: Aetna Better Health of Virginia, the Cardinal Care plan, is its own contract

Cigna Healthcare

Behavioral health goes through Evernorth
  • Right now the door is shut: Evernorth paused new individual and clinic behavioral health applications on June 1, 2026 and signaled a reopen after September 1. That pause is national, not a Virginia decision
  • Exceptions: facilities are exempt and applications submitted before June 1 are unaffected
  • Usually: up to about 90 days once open, with re-attestation every 120 days. We track the reopen and file as soon as the door opens

Separate door: Evernorth Behavioral Health

Kaiser Permanente of the Mid-Atlantic States matters in Northern Virginia and is not a fully closed system. Its region covers Maryland, Virginia and the District of Columbia, and it does contract with community providers there, including through its HealthChoice products, on top of its own Permanente medical group. Do not carry over the Oregon or California picture. The realistic read is that Kaiser is worth a request if you practice inside the DC metro footprint, and not worth planning your first six months around. Regional plans have thinned: Piedmont Community Health Plan in Lynchburg appears to have wound down its insurance business and its old web address now redirects to Centra Health, which we treat as a check-before-you-count-on-it item rather than a settled fact. Medicare and the Cardinal Care Medicaid plans are scoped separately from a commercial package.

Carry a plan we didn’t list? Add it.

TRICARE East is the most Virginia-specific opportunity on this list, because of Hampton Roads, Quantico, the Pentagon and the rest of the military footprint. Humana Military says it is not currently accepting requests to join the medical, surgical or ancillary network, but it is accepting requests for psychiatry, mental health, substance abuse and autism providers. So the door that’s closed to most specialties is open to behavioral health. You have to be TRICARE-certified first, then submit a network participation request for the East region, and Humana Military allows one entry per tax ID. Network acceptance changes, so we confirm current status rather than assuming.

The Local Choice and the Commonwealth of Virginia employee programs are the other quiet one. Medical, pharmacy, behavioral health and the employee assistance program on the statewide plans run through Anthem, with a Sentara Vantage HMO option where an employer has selected it. You reach those members through your existing Anthem or Sentara contract rather than a separate one, and in parts of Virginia those two programs are a large share of the commercially insured population. That’s a practical argument for holding Anthem even when your mix looks otherwise. Union trusts and rented networks like MedCost work the same way: give us the plan name and we find the real route.

What we need from you

Send these once and we can start.

You give us this in one intake. Then we fill out the applications. No passwords, no patient information, and nothing gets submitted until you’ve read it and signed.

  • Your individual NPIPlus the Type 2 if you bill under a group. Both have to be active in PRSS before a Cardinal Care plan will load a Medicaid contract.
  • Active Virginia license and DEAWatch the expiration date. Since July 1, 2025 there’s no grace period on the Medicaid side, and a lapse terminates your DMAS enrollment and every plan contract at once.
  • CAQH attested and authorizedSet authorization to Global if you’re going through Carelon for Anthem behavioral health. Optum’s Virginia page states CAQH participation is required here.
  • Delegated PRSS accessSo we can complete your DMAS enrollment and each plan application without password sharing. We also need the correspondence address and email on file, because that’s where revalidation and license-expiration notices go.
  • Every service address, and your telehealth mixIn Virginia this decides your Blue plan. Addresses east of Route 123 in Fairfax and Prince William, plus Alexandria, the city of Fairfax, Vienna and Arlington, are CareFirst territory rather than Anthem.
  • Malpractice certificateNaming you, or a carrier-produced roster face sheet. CareFirst asks for a copy of the policy as part of the application upload.
  • Five years of work history and your disclosuresMonth and year, with any gap over six months explained, plus ownership, controlling interest and managing employee disclosures for the DMAS side.
  • Entity name, EIN and W-9One per tax ID. CareFirst requires a W-9 for a new practice, and it’s part of the DMAS enrollment file.
  • Bank details for EFT and remittanceCollected through a secure task. Credentialing without remittance loading means approved claims that still don’t pay you.

Virginia licenses behavioral health providers by service type through the Department of Behavioral Health and Developmental Services, and the licensable list is built around program-style services rather than ordinary office visits: assertive community treatment, crisis stabilisation and mobile crisis, intensive in-home, mental health skill building, partial hospitalisation and intensive outpatient, substance use and opioid treatment, and residential services. It also shows up as a payer gate rather than only a state one, because DMAS asks addiction treatment providers to send the matching DBHDS license to PRSS and to each plan before credentialing can start. We ask about your service mix at intake and flag it early if it points that way, then point you to DBHDS. We don’t give legal advice and we don’t file a facility or agency license for you.

How it works

You answer once. We do the paperwork.

You can buy online without booking a meeting. Nobody has to sell you anything first.

Buy the package

Published price and scope. No call needed.

One intake

Short and guided. It asks more only where your answers call for it.

We prepare everything

Your PRSS enrollment, each Cardinal Care plan application and every commercial application, filled out from what you told us.

You review and sign

Read it, change anything, sign. Nothing goes out until you say so.

We submit and track

You see what’s done, what’s waiting on a payer, and when you can bill.

What we commit to

Tracking is included. Every package comes with Command Suite access, so you can see where each payer application stands, what we are working on, what is waiting on a payer, and what we still need from you. You are not left guessing between the purchase and the finish.

If something we delivered does not work the way we said it would, we fix it at no charge for 30 days after delivery, including one stabilization review. That covers our own work. A new request, another payer or provider, or a change of scope is quoted separately.

Built to keep working after we are done. Everything we set up is built for the practice you are growing into, not only the one you have today. When the engagement ends you own the accounts, the documentation, and the systems, and they keep running without us.

Questions we get

Virginia credentialing questions

Does Virginia pay me for the credentialing wait?
On the commercial side, yes. Under Va. Code 38.2-3407.10:1, claims for services rendered while your application was pending, submitted according to the carrier’s claims policies, have to be adjudicated and paid no later than 40 days after you’re credentialed and contracted, at the in-network rate you’d have received had you already been participating. The limits are real: it excludes Medicare Advantage, it doesn’t cover non-covered services, and it’s void if credentialing is denied or no contract is executed. It also doesn’t reach Medicaid.
When does my application count as complete?
Thirty days after the carrier receives it, unless the carrier notifies you that it isn’t. That’s been the rule since January 1, 2024, and it’s the most useful sentence in the statute. In most states a file sits for months because nobody ever formally calls it complete, so no clock ever starts. Virginia makes the carrier say what’s missing inside 30 days or the clock runs anyway. The 60-day decision follows from there.
Anthem or CareFirst? How do I know?
Your street address decides it, and the line is Route 123. Anthem is the Blue licensee for Virginia except the city of Fairfax, the town of Vienna and the area east of Route 123. CareFirst holds that corner along with Alexandria, Arlington County and the parts of Fairfax and Prince William Counties east of 123. If you practice in Arlington or Alexandria, CareFirst is your local Blue plan and Anthem isn’t. Reaching the whole in-state Blue population usually means both, and that’s two licensees inside one state rather than a contract per state.
Is Sentara taking behavioral health applications?
Not at this verification. Sentara says its behavioral health network is full and sufficient across all service locations and specialties, and interested providers go on a waiting list. That’s worth knowing before you spend the effort, because Sentara is one of the largest behavioral health managed care organizations in the state with over 4,000 behavioral health providers, and plenty of Virginia advice still assumes the panel is open. We get you on the list and check the status rather than filing into a closed network.
Who handles behavioral health for Virginia Medicaid?
Nobody separate, and that’s a recent change. Magellan of Virginia held the behavioral health services administrator role until October 31, 2023. Since November 1, 2023, fee-for-service authorisations go through Acentra Health, formerly Kepro, and claims go to DMAS. For a managed care member it’s simply their Cardinal Care plan. What replaced the carve-out is a service-level gate: many services are keyed to a specific DBHDS license and taxonomy, so the question is whether your enrollment matches the service you intend to bill.
My license lapsed briefly. Is that a problem?
On the Medicaid side, yes, more than it used to be. Effective July 1, 2025 DMAS removed the 90-day grace period that followed a license expiration. A lapse now terminates the enrollment agreement, and a returning provider is enrolled based on the month they apply or ask for reinstatement, so you lose the retroactive billing you’d otherwise have had. DMAS sends courtesy notices at 90, 60 and 30 days before expiration, which is exactly the kind of date we calendar for you.
Half my patients are military families. What’s the route?
TRICARE East, administered by Humana Military, and it’s unusually good news for behavioral health. Humana Military says it isn’t currently accepting requests to join the medical, surgical or ancillary network, but it is accepting requests for psychiatry, mental health, substance abuse and autism providers. You have to be TRICARE-certified first, then submit a network participation request for the East region, and there’s one entry per tax ID. Network acceptance changes, so we confirm the current status before planning around it.
Do you need my CAQH password?
No, and we won’t ask. We’re added as an authorized practice manager, which lets us keep your practice data current and authorize payers. You complete and attest your own profile and you sign your own paper applications. Virginia has no state-designated credentialing database in statute, but CAQH is what every major carrier here runs on, so a lapsed attestation stalls every commercial application at the same time.

Keep reading

Related

Virginia PMHNP scope of practiceWhat Virginia allows you to do, which is a separate question from who pays you.
Maryland payer enrollmentThe other half of the DC metro market, with its own enrollment portal transition.
West Virginia payer enrollmentA five-business-day Medicaid clock and a naming trap that catches out-of-state credentialers.
North Carolina payer enrollmentA credentialing clock with no retroactive bridge, so the wait comes out of your pocket.
Opening your own practiceEntity, identifiers, payers, EHR and billing setup.
Adding a provider to your clinicFirst-time credentialing into contracts you already hold.
Changing your entity or tax IDMoving panels without breaking the money.
All 51 state guidesEvery state’s Medicaid path, plan roster and credentialing rules.

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Where this comes from

  • Code of Virginia 38.2-3407.10:1: 60-day credentialing decision, application deemed complete 30 days after receipt from January 1, 2024, claims during pendency paid within 40 days of credentialing at the in-network rate, Medicare Advantage excluded verified July 26, 2026
  • Code of Virginia 38.2-3407, any willing provider: terms and conditions may not discriminate unreasonably, and no willing provider shall be excluded verified July 26, 2026
  • Code of Virginia 38.2-3407.10, health care provider panels: carriers must supply an application and terms on request, and 90-day notice before termination without cause verified July 26, 2026
  • Virginia Department of Medical Assistance Services, PRSS provider enrollment and revalidation, the five-year cycle and the 90, 60 and 30 day notices verified July 26, 2026
  • Virginia Medicaid Enterprise System: from July 1, 2025 the post-license-expiration grace period is eliminated and enrollment is dated to the month of application or reinstatement, and plans cannot pay non-enrolled providers verified July 26, 2026
  • Virginia Medicaid Enterprise System: the Cardinal Care Managed Care contract effective July 1, 2025, the five awarded plans, and Molina’s exit on June 30, 2025 verified July 26, 2026
  • Virginia Department of Medical Assistance Services: Magellan of Virginia’s behavioral health services administrator contract ended October 31, 2023, with Acentra Health handling service authorisations from November 1, 2023 verified July 26, 2026
  • Virginia Department of Medical Assistance Services, ARTS credentialing: DBHDS license by ASAM level, the Preferred OBAT attestation, credentialing checklist and staff roster, and the OBAT recognition letter verified July 26, 2026
  • Virginia Administrative Code 12VAC35-105-30 and the DBHDS Office of Licensing, licenses issued by service type verified July 26, 2026
  • Anthem Blue Cross and Blue Shield, commercial network participation and digital provider enrollment through Availity verified July 26, 2026
  • Carelon Behavioral Health, Virginia quick reference guides for the Anthem commercial and HealthKeepers Plus lines, and the March 1, 2023 rename from Beacon Health Options verified July 26, 2026
  • CareFirst BlueCross BlueShield, professional credentialing requirements, the service area definition, and behavioral health brought in-house from Magellan verified July 26, 2026
  • Sentara Health Plans: behavioral health network closed to new applicants with a waiting list, CAQH before the behavioral packet, and the 30-day change notice verified July 26, 2026
  • Optum Provider Express, Virginia: any-willing-provider recognition, prescribers in all counties, and the CAQH requirement verified July 26, 2026
  • Aetna, request for participation, 45-day network need response, and the separate behavioral health form verified July 26, 2026
  • Evernorth Behavioral Health, credentialing timing and the June 1, 2026 national application pause verified July 26, 2026
  • Kaiser Permanente Mid-Atlantic States, community provider participation across Maryland, Virginia and DC verified July 26, 2026
  • Humana Military, TRICARE East: network requests open for psychiatry, mental health, substance abuse and autism, certification required first, one entry per tax ID verified July 26, 2026
  • The Local Choice, Virginia Department of Human Resource Management: statewide plans with medical, pharmacy and behavioral health through Anthem, plus the Sentara Vantage HMO option verified July 26, 2026

Written by Ryan Berg, founder of AdvanceAPractice. 16 years in healthcare revenue cycle and credentialing.

Facts on this page were verified July 26, 2026 and are next due for review September 28, 2026.

Payer programs, plans and timelines change. Everything here carries a verification date and gets re-checked on a review cycle; this record is next due for review on September 28, 2026. Approval and effective dates are controlled by each payer and by the state, and credentialing commonly runs 60 to 120 days per payer. This page covers payer operations. It isn’t legal, tax or scope of practice advice.