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Virginia payer enrollment guide

How enrollment works in Virginia with Medicare, Virginia Medicaid and the major commercial plans, in the order that usually matters, with each rule taken from the payer's or the government's own page.

Checked against each source on October 12, 2026. Payers change their processes, so confirm the current steps with each one before you file.

1. The order that usually matters

Most practices run three tracks at once: Medicare, Virginia Medicaid with its five Cardinal Care health plans, and the commercial plans. Three ordering rules come straight from the sources:

Virginia Medicaid before the Medicaid plans. DMAS says "Virginia Medicaid MCOs are prohibited from contracting with providers who are not enrolled in PRSS," the state's provider portal. Our Virginia Medicaid enrollment page covers that step.
A current CAQH profile before most commercial applications. Anthem, Aetna, Optum and Cigna all work from it, and each plan has to be authorized to see it.
Medicare through PECOS. Clinics and group practices use the CMS-855B; physicians and non-physician practitioners use the CMS-855I.

Sources (checked Oct 12, 2026)

2. Virginia's credentialing law

Virginia Code § 38.2-3407.10:1 sets rules for carriers when a new clinician applies. They "apply only if a contractual relationship exists" between the carrier and the clinician or the practice that employs them, so they matter most when you add a clinician to a plan you already contract with.

60-day decision. The carrier "shall approve or deny new provider applicant credentialing applications within 60 days of receiving a completed application."
When an application counts as complete. Since January 1, 2024, an application is deemed complete within 30 days of the carrier receiving it, unless the carrier gives notice that it is not complete.
Pending-period claims. Claims for services during a pending application must be paid no later than 40 days after the clinician is credentialed and contracted, at the in-network rate.
Patient notice. To bill for that period, the clinician must tell patients in advance, in writing or electronically, that a credentialing application has been submitted to their plan.
If credentialing is denied. The law does not require in-network payment, and the clinician may not collect from the patient for services from the date the completed application was submitted until the denial notice arrived.
Scope. The section does not apply to Medicare Advantage plans. It does apply to Medicaid HMOs, and the Cardinal Care managed care contract repeats the 60-day and 40-day rules.

Sources (checked Oct 12, 2026)

3. CAQH (now DataSpring)

New name. CAQH now operates as "DataSpring, powered by CAQH." Many plan pages still call the profile CAQH ProView.
Re-attest every 120 days (every 180 days in Illinois). DataSpring says a profile that is not attested in time changes to Expired.
Authorize each plan. Aetna asks you to "designate Aetna as an authorized health plan so we can access your application."
Status matters. Anthem looks for a CAQH status of "Initial Application Complete or Reattestation." Cigna asks for "Initial Profile Complete or Re-attestation."

Sources (checked Oct 12, 2026)

4. Commercial plans

How each plan starts the process and what it publishes about timing. These are each plan's own estimates, not promises.

Plan	How it starts	What the plan publishes
Anthem (Virginia commercial)	Online application on Anthem's Virginia "Join our network" page. Credentialing uses CAQH ProView.	"Typically takes 45 days" from receipt of your completed CAQH application. Recredentials every three years. Anthem's Virginia service area excludes the Northern Virginia suburbs of Washington, D.C.
Aetna	A request to join. Aetna first evaluates the need in your area and decides whether contracting, credentialing or both are required.	Credentialing and contracting are separate, and both must be complete. Aetna pulls the application from CAQH ProView. No individual-clinician timeline is stated on its join page.
UnitedHealthcare	Onboard Pro, in the UnitedHealthcare Provider Portal.	"Generally takes up to 45 calendar days or more" once the application is complete. A contract to review is not an approval. Allow up to 60 days for the contract to be loaded after approval and signing.
Optum Behavioral Health (UnitedHealthcare behavioral health)	providerexpress.com or 800-817-4705. Optum handles behavioral health credentialing and contracting for UnitedHealthcare.	Credentialing starts only after Optum decides it wants to pursue a contract. An incomplete or expired CAQH profile can slow down or cancel the application. No timeline found on the pages we checked.
Cigna Healthcare	A pre-application step to confirm you meet the basic guidelines.	"Typically takes 45 to 60 days" after the application packet arrives; approved providers are usually loaded within 10 business days. Behavioral health is Evernorth.

Plans can limit who they add. Aetna says that, "based on state law," it reviews each request against its current network in that area, and its join page describes denying a request when the panel is not open.

Sources (checked Oct 12, 2026)

5. Medicare

Where. PECOS, CMS's online enrollment system. CMS says PECOS applications "tend to process faster than paper applications."
Effective date. For physicians and non-physician practitioners, the later of the filing date of an application that is later approved, or the date services began at the new practice location. Medicare allows billing up to 30 days before the effective date if circumstances prevented enrolling in advance.
Processing. CMS's standard for its contractors is to process online initial applications that need no site visit, development or fingerprinting within 50 calendar days. That is a performance standard for the contractor, not a promise to an applicant.
Changes. Report a change of ownership, an adverse legal action or a practice location change within 30 days, and all other changes within 90 days.
Revalidation. Generally every five years. CMS posts due dates seven months ahead, the contractor sends a notice about three to four months before the due date, CMS does not grant extensions, and Medicare does not pay for services during a period of deactivation.

Sources (checked Oct 12, 2026)

6. Virginia Medicaid and Cardinal Care

Medicaid has its own two steps: enroll with DMAS in PRSS, then join each Cardinal Care plan. The details, including each plan's join route and reported timelines, are on our Virginia Medicaid enrollment page.

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This page is general information, not legal advice. Rules and payer processes change; always follow the payer's or agency's current instructions. Payer, agency and product names belong to their owners and are used only to describe what each step involves.