Prior Authorization in Virginia
Soft Home Global provides authorizations submitted ahead of the date of service and chased to a decision for Virginia practices and billing companies at $1,900 per seat per month. Full time, worked during Virginia business hours, inside your own system.
What is specific to Virginia
Cardinal Care moved most Virginia Medicaid members into managed care plans, while practices in northern and coastal Virginia also carry heavy TRICARE and federal employee health benefit volume.
Virginia’s Medicaid program is Cardinal Care (Virginia Medicaid). Practices with a meaningful Cardinal Care (Virginia Medicaid) mix usually need it worked as its own queue rather than mixed into commercial follow-up, because the submission path, the timely filing window and the appeal route are all different.
Medicare here is adjudicated by Palmetto GBA, jurisdiction JM — shared with North Carolina and West Virginia, but not with Kentucky (CGS), Maryland (Novitas) or Tennessee (JJ). CMS publishes the jurisdictions; checked September 2026.
What a prior authorization seat does in Virginia
Submitted before the date of service and chased through the payer's decision window.
An authorisation found after the visit is a write-off, not a denial to appeal. In Virginia the work is submitting ahead of scheduling and chasing the decision, against a payment clock that starts only once a clean claim lands.
- Authorizations submitted ahead of scheduling, not after
- Status chased rather than waited on
- Peer-to-peer reviews scheduled when required
- Clinical documentation gathered before submission
- Expiring authorizations flagged before they lapse
- Worked during Virginia business hours, not queued overnight
For the statute behind all of this — Virginia’s prompt-pay deadline, its Medicaid filing limit, and the wrinkle that catches people out here — see the Virginia billing page.
Cardinal Care (Virginia Medicaid), in practice
Virginia Medicaid runs under one unified brand, Cardinal Care, with managed care (Cardinal Care Managed Care) delivered by five MCOs: Aetna Better Health of Virginia, HealthKeepers, Inc. (Anthem HealthKeepers Plus), Humana Healthy Horizons in Virginia, Sentara Community Plan, and UnitedHealthcare of the Mid-Atlantic, Inc. Source: dmas.virginia.gov
Workers' compensation is billed off a mandatory, region-specific state fee schedule rather than 'prevailing community rate': Va. Code § 65.2-605 defines six 'medical communities' (Northern, Northwest, Central, Eastern, Near Southwest, Far Southwest, assigned by ZIP code) and provides that 'Separate initial Virginia fee schedules shall be established for fee scheduled medical services ... within each of the medical communities,' with 'The Commission's regulations that establish the initial Virginia fee schedules shall be effective on January 1, 2018.' The same CPT code pays differently depending on which of the six regions the service was rendered in. Source: Code of Virginia
For authorisations it decides who you ask. A carve-out means the rules, the portal and the turnaround belong to a different administrator from the one handling the rest of the member’s care, and an authorisation obtained from the wrong one is not an authorisation.
Working Virginia hours
Virginia runs on Eastern time, 10 hours behind our floor in Rawalpindi. To be at a desk for your nine to five, the shift here runs 7pm to 3am, and 6pm to 2am once the clocks go forward. Pakistan does not observe daylight saving, so the shift moves on this side rather than yours.
That is the part that decides whether follow-up happens at all: a payer’s phone lines are open on Virginia hours and nobody else’s.
What it costs in Virginia
$1,900
Per seat, per month, in US dollars — $22,800 a year for one full-time person, forty hours a week, on Virginia hours. No annual contract, no percentage of collections, no setup fee and no software to buy. Seat prices across all roles in Virginia run $1,500 to $2,500; the full list is published.
That is the entire invoice. Run your own figures against a percentage vendor or a hire rather than take ours.
Getting started in Virginia
About a week from a signed agreement to a person working your queue, and that week of training is not billed on top. The week, step by step, and what is signed before anyone has access.
If working with staff outside the United States is new to your practice, see how a medical billing company structures that seat and why offshore medical billing does not have to mean losing visibility into the work.
Questions
Do you work with Virginia practices?
Yes. Virginia accounts are worked during Virginia office hours rather than queued overnight, because a payer's phone lines are open then and at no other time.
What is different about Virginia?
Cardinal Care moved most Virginia Medicaid members into managed care plans, while practices in northern and coastal Virginia also carry heavy TRICARE and federal employee health benefit volume.
Which Medicare Administrative Contractor covers Virginia?
Palmetto GBA, the A/B MAC for jurisdiction JM. Medicare Advantage and commercial plans run their own authorizations; for traditional Medicare, the hospital outpatient services on CMS’s prior authorization list are reviewed by this MAC.
When does a Virginia payer have to pay a clean claim?
40 days from receipt of the claim (no separate electronic/paper deadline in the statute). The authorization gets the service approved; this is the deadline for paying the claim that follows it, once that claim is clean.
How fast must Cardinal Care (Virginia Medicaid) decide a prior authorization?
Under the federal CMS-0057-F rule, from 1 January 2026: 72 hours for an expedited request and seven calendar days for a standard one, for Medicaid fee-for-service and Medicaid managed care plans alike, counted in calendar time whether the request went by portal, fax or phone. The calculator at softhomeglobal.com/prior-auth-deadline works out the date.
How much does prior authorization cost in Virginia?
$1,900 per seat per month — $22,800 a year for a full-time person, forty hours a week. Every seat price is published at softhomeglobal.com/pricing.
What hours will somebody actually be working our Virginia queue?
Virginia is on Eastern time, 10 hours behind Rawalpindi. The shift here runs 7pm to 3am so your seat is at a desk for your full working day, shifting to 6pm to 2am while daylight saving is in force — Pakistan does not observe it, so the change happens on our side.
Do you handle Cardinal Care (Virginia Medicaid) as well as commercial payers?
Yes, and as its own queue rather than mixed into commercial follow-up. Cardinal Care (Virginia Medicaid) has its own submission path, its own filing window and its own appeal route, and working it in the same worklist as commercial claims is how the deadlines get missed.
Is this a percentage of what you collect?
No — a flat monthly rate per seat, published at softhomeglobal.com/pricing. A percentage bills you most in your best month and points the vendor at the easy accounts.
Next step
One seat on your Virginia work
Twenty minutes on a call is enough to tell whether this fits. If it does not, I will say so.
Or write to ops@softhomeglobal.com