Medical billing services in Virginia

Billing in Virginia: what's different

The rules below change how a claim is filed and paid in Virginia. Each line links to the official page it was read from, and the date at the top of this page is when it was last checked.

Rules that change how Virginia claims are billed

• Downcoded claims must show the CARC and RARC and get a 180-day dispute window⁵

  Under Va. Code 38.2-3407.15, a carrier may downcode only through a natural person or a system that applies correct coding standards and weighs everything the provider documented on the claim. The explanation of payment must say the claim was downcoded, name the claim adjustment reason and remittance advice remark codes, and show how to dispute. The provider contract has to allow at least 180 days from the downcoding notice to file a dispute, a natural person decides every dispute, and you may dispute claims in batches per patient.

• A paid claim can only be taken back within 12 months, with 30 days' notice⁵

  A commercial carrier may retroactively deny or recover a paid claim only after naming the specific claims in writing and explaining why, and only if the claim was fraudulent, was paid twice or covered services not delivered, or the payment is no more than 12 months old. The carrier must give 30 days' notice before any recovery, unless you agreed in writing to offsets after the 12-month mark. A contract amendment takes effect only if you receive it at least 60 calendar days ahead and do not give notice to terminate within 30 days.

• Out-of-network emergency and surgical claims go to negotiation, then arbitration¹¹

  An out-of-network clinician cannot balance bill a patient for emergency care, or for surgical or ancillary services at an in-network facility; the patient owes only in-network cost sharing. The carrier must offer a commercially reasonable amount within 30 calendar days of a clean claim, you have 30 calendar days from payment to dispute it, and the two sides have 30 calendar days from the initial offer to negotiate. After that, either side can start arbitration by notifying the State Corporation Commission within 10 calendar days and can bundle claims for the same carrier and related procedures falling within two months of each other.

• Every Cardinal Care network clinician is enrolled and revalidated in PRSS¹

  Fee-for-service providers and Cardinal Care network providers alike must be enrolled in PRSS and revalidate at least every five years. DMAS sends the revalidation notice at least 90 days before the enrollment period ends, and a provider that misses the due date loses participation in fee-for-service and in every plan network until it re-enrolls.

• For a denied fee-for-service claim, DMAS wants a corrected claim, not an appeal¹³

  DMAS asks providers to correct and resubmit a denied fee-for-service claim instead of appealing, because an appeal addresses only the denial reasons on the remittance advice and does not reprocess anything. Resubmitted claims are processed within 30 days or less, and a second denial comes with its own edits and new appeal rights. Members in a Cardinal Care plan are billed to that plan, not to DMAS.

Services for Virginia practices

Remitwright serves Virginia practices remotely, inside the practice management or EHR system the practice already uses. A dedicated biller works the account; nothing is pooled. Each service below explains what that biller does.

• Medical billingClaims worked by one named biller
• CredentialingEnrollment, CAQH and PECOS kept current
• Eligibility verificationCoverage and benefits checked before visits
• Prior authorizationAuths requested, tracked, attached to claims
• Denial managementEvery denial read, worked and appealed
• A/R follow-upUnpaid claims chased before filing limits