State-Specific Guidance›Virginia Medicaid Billing Workflow

Virginia Medicaid Billing Workflow

Overview

(As always, private pay is generally self-regulating within the confines of state law and regulatory processes. This article focuses on Medicaid billing in the state of Virginia.)

In the state of Virginia, there are some unique billing processes.

Aggregators: Anthem requires Netsmart as its aggregator and clearinghouse. Humana Healthy Horizons requires HHAX as its aggregator and clearinghouse. Data is exported upon billing in both cases in the state of Virginia. Note that while most payers allow for billing up to a year late, they have advised that "claims must be submitted within one calendar month to avoid claim denials."

Clearinghouses: most clearinghouses will handle all your claims for an additional fee, but some will provide free services for a single payer. Most customers find it easier to set up, test, and manage claims through a single portal, or at most two.

  • Aetna Better Health of Virginia is free through Office Ally

  • Humana Healthy Horizons is free through HHAx

  • Availity is no longer used with Humana as of October 29, 2025

  • Sentara prefers Availity

  • Molina is now Humana and is required to be sent through HHAx

  • Batch EDI claims submissions require a premium Availity subscription.

  • United Healthcare Community Plan does not have a preferred clearinghouse

  • Straight Medicaid is free through Conduent

For Ankota users, that means in addition to regular EVV services, Ankota also delivers visit data to the desired clearinghouse to ensure state requirements are met.

NOTE: As of February 2025, the following MCOs are currently not accepting new Agencies:

  • Anthem

  • Molina

  • United Health Care

NOTE: As of October 2025, Humana visits must be billed through HHAx. Billing through another party such as Availity is not permitted.

This article covers:

  • Critical Pathway

  • Set-up and Testing

  • Pre-Billing

  • Billing Management for Medicaid Visits

  • Corrected Claims

  • Remittance Advice Management (835s)

  • Further Details

Critical Pathway

For a simple overview of key admin system maintenance, see the Virginia Critical Pathway document with linked steps.

Set-up and Testing

Caregivers are required to have 1 profile in Ankota. (Admins can have both caregiver and admin profiles in order to access different levels of permissions.) Caregivers must be paid in a single payroll per Virginia standards.

NetSmart

Ankota users in Virginia must register for EVV so that their Anthem claims can be billed. (Ankota will deliver visit data to NetSmart/Mobile Caregiver Plus.) This registration will ensure NetSmart will accept their data and give providers access to the NetSmart log-in. Internally, Ankota users are automatically set up for delivery of EVV visit data to the state as part of implementation. Testing is not necessary.

Alternately, send an email to dl_evv_sales@ntst.com and provide them with the following information:

  • Agency Name

  • Contact Email

  • Phone Number

  • Payer – Anthem

  • Provider Name

  • Provider EIN

  • Provider NPI

  • Medicaid ID#

They will send a confirmation within 24-48 hours. If nothing is received, reach out to them at 833-4-TELLUS and check status.

NOTE: To upgrade to a paid NetSmart account (for non-Anthem payers in Virginia; Anthem is free) so that all billing is through one clearinghouse, this is available, but the cost of adding payers has increased. As of the last update in 2022, it was $400/payer for set-up plus $15 per month.

HHAX Set-up

Humana Healthy Horizons claims are sent to HHAeXchange. Ankota users in Virginia under this plan providing any of the following services must register for HHAeXchange: In-Home Personal Care, In-Home Respite, and Home Based Supportive Care (HCSS).

All services requiring an in-home visit are subject to the EVV mandate including self-directed services except for live-in caregivers. Internally, Ankota users are automatically set up for delivery of EVV visit data to the state as part of implementation, but registration ensures HHAeXchange will accept the data and give providers access to credentials and the HHAeXchange log-in.

NOTE: Non-EVV visits can and should be billed through Availity, such as Service Facilitation visits.

To ensure success with HHA:

  1. Register with HHA

  2. Request the EDI payer rates be set up for Humana for your system

  3. Deliver credentials to Ankota so your data can be delivered (user/pw for your SFTP)

  4. Request Ankota set up your system for HHA data delivery, reason coding, Approval Assistant configuration, etc.

To register with HHA, providers must go to the Virginia HHAeXchange portal and complete the registration form. Also, register to send HUMANA visits through HHAx. The following information is needed:

  • Provider name: YOUR COMPANY NAME

  • Provider contact name and email address: NAME, EMAIL

  • Provider Medicaid ID

  • Provider Tax ID

  • Vendor name: Ankota LLC

  • Vendor address: 1 Franklin Street, Suite 360B, Boston, MA 02110

  • Vendor contact name & contact information: Sharon Dodge, COO, sharon.dodge@ankota.com, 844-4-Ankota, extension 703

  • If you want HHAx to bill your data, request that option

It is necessary to create a username/password through the SFTP Setup on HHAx portal for successful billing as well as having HHAx configure your account to bill HUMANA visits. See the HHAx SFTP Username and Password Setup video for instructions.

Send Ankota the following information:

  • Your HHAeXchange username and password from the SFTP Setup

  • Any HHAeXchange communications

  • Your provider Medicaid ID, Tax ID, and taxonomy codes

Questions about VA EVV can be directed to:

Virginia collects the following information:

  • Type of service

  • Person Serviced

  • Dates of Service

  • Location of Service

  • (Reason & Action codes if needed)

  • Name of Caregiver

  • Times of Service (start & end time)

  • Client data

    • Medicaid ID in the Medicaid ID field

    • Other ID or same ID in the Client ID field

    • Client address

    • Primary diagnosis code (this must be the diagnosis CODE, not the description, and it must be the code assigned by the state, not a general valid diagnosis code)

  • Caregiver demographic data

    • First Name Last Name

    • DOB

    • SSN

    • ID & Matching Caregiver Code (do not skip UNLESS you do not want the caregiver to send, like the Ankota Support caregiver)

    • Gender

    • Type: 'Both', 'Skilled', or 'Non-Skilled' (this is under Roles); no other Role is allowed by HHAx

    • Hire date

    • Valid email and phone format (if email and phone are entered)

    • Valid Address (State and 5-digit ZIP required)

    • Role - Skilled, Non-Skilled, or Skilled

Critical Notes:

  • If switching to Ankota from HHAx EVV, all visits must be closed out and billed in HHAx (or notify them you do not wish to bill) before they will allow you to create your username and password for the integration. This means you cannot even have scheduled current/future visits remaining in the HHAX system or the integration with Ankota will be blocked.

  • Once ready to transition (and any visits in HHAX are closed out/billed), get username and password credentials so that Ankota can deliver your data to HHAx to your SFTP folder path. Create these in your portal and share them with Ankota. Ankota can then enter them and confirm the integration is ready to move forward with HHAx.

  • PA does not require caregivers. Also, not all visit types are required to go to HHAx.

For further questions, contact Pennsylvania HHAX 844-626-6813 option 3 OR phwproviderrelations@pahealthwellness.com or the general 888-801-1660 provider line, or use the HHAX portal to create a Support ticket through the right-hand menu.

Availity

Ankota users in Virginia must register for Availity if they wish to use them for non-Anthem MCOs. Ankota will set up Availity during implementation upon request. Testing is not necessary. A paid account is needed for some MCOs and for straight Medicaid. Complete the full set-up to have automated file transfer, including providing Ankota with your Availity FTP user name and password.

Conduent

Ankota users in Virginia must register with Conduent if they wish to use them. Ankota will set up Conduent during implementation upon request. See the Conduent registration, set-up, and testing walkthrough for details.

Office Ally

Office Ally is the selected clearinghouse for Aetna Better Health of Virginia. They do accept some other MCOs without charge, but generally there is a fee for "Non-par" (non-participating) payers. This can be set up by request.

Pre-Billing

Successful billing starts at the beginning of the client's creation. The processes below will lead to successful billing.

Client Management

  • Client/Caregiver Entry

  • Setting Authorized Service for Clients (entering authorizations)

In VA, if a client receives services from a live-in caregiver and a regular caregiver, the decision whether they need an extra authorization for those live-in services is determined by the Payer. Each payer may handle the situation differently. Agencies are advised to reach out to case managers and/or Payer in this case (Sentara, Anthem, United Healthcare, etc.).

  • Schedule Visits - Calendar-Based Scheduling (or Creating Visits from Patterns)

Visit Management

  • Caregivers complete visits or timesheets are entered manually through the office

Critical note: For accurate DMAS reporting, when a caregiver works Respite time, they must report at least ONE Respite item. For the mobile app, they will report the Respite item using the drop-down list. For telephony, they will report a Respite code.

  • Visits are approved automatically or visits are approved by office

  • Ensure visits are closed, then review and clear the Visit Approval Dashboard

Critical note: For NetSmart, apply Exception Codes as needed (REQUIRED if missing EVV clock-in or clock-out).

Prevention of Errors/Rejected Claims

  • Watch warnings on the Action Center (for missing auths, primary diagnosis codes, IDs, etc.) and address as needed

  • Watch warnings on the Visit Approval Dashboard and address as needed

  • Ensure that name spellings, First Name/Last Name separation, Medicaid ID, admission ID (on auth), and DOBs are entered correctly

  • Finally, manage rejections

The Landing Dashboard will highlight necessary actions, including managing visits as needed.

Billing Management

General Management

Successful billing starts at the beginning of the client's creation. The processes below will lead to successful billing.

Client Management

  • Setting Authorized Service for Clients (entering authorizations)

  • Schedule Visits - Calendar-Based Scheduling (or Creating Visits from Patterns)

Visit Management

  • Caregivers complete visits or timesheets are entered manually through the office

  • Visits are approved automatically or visits are approved by office

  • Ensure visits are closed, then review and clear the Visit Approval Dashboard

  • NetSmart visits require Reason Codes if they are missing critical EVV data such as a clock-in, clock-out, GPS data, or telephony data

Prevention of Errors/Unmatched/Rejected Claims

  • Watch warnings on the Action Center (for missing auths, primary diagnosis codes, IDs, etc.) and address as needed

  • Watch warnings on the Visit Approval Dashboard and address as needed

  • Ensure that name spellings, First Name/Last Name separation, Medicaid ID, and DOBs are entered correctly

  • If preventative actions fail, watch for Rejection Response Files and address those issues as needed

NetSmart Billing

See the detailed overview of Tellus billing.

Currently, only Anthem is required to go through NetSmart, and this is free. Providers may choose to send other billing through NetSmart for a start-up + monthly fee. Related articles cover reason codes, reading Tellus response files, managing cancellations, managing data exports, single-export corrections, and mass export corrections.

Note: NetSmart should receive all authorizations directly from the state, so if a client is missing an authorization, reach out to NetSmart support right away.

Availity Billing

Availity is commonly used for Virginia MCOs but is NOT usable for Humana as of October 29, 2025. See the detailed overview of Availity for billing, troubleshooting, and more.

Conduent Billing

Conduent is required for straight Medicaid billing in Virginia (although NetSmart and Availity will process them for a fee). See the detailed overview of Conduent for billing, troubleshooting, and more.

Corrected Claims

Generally, claims corrections are handled one of two ways:

  • Update the claims in Ankota and re-send

  • Update the claims in the location where they were sent

Use of the Approval Assistant is recommended to simplify visit corrections. Only use the Duration adjustments section if there are known, strict limitations on the allowed work duration for the selected visit type.

See the NetSmart, Availity, and Conduent articles for more on these processes.

Remittance Advice Management (835s)

Remittance advice files, or 835s, may be provided in response to filing Medicaid claims. Optima normally provides 835s through the Availity portal. These are essentially state receipts of payments. If provided, they can be uploaded to Ankota for automatic application of payments in the A/R records. Ankota does not provide 835s; if not received from the state, arrangements must be made to receive them.

  • Process Remittance Advice (Upload 835 "receipts" received from MMIS into Ankota)

  • Post Manual Payments

  • Review Billing Reports

See also: Collections Report, Exceptions Report.

Further Details

These additional resources may also be of use:

  • The Ankota Training Overview, including videos

  • Daily Adjustments

  • Manual Visit Entry

  • Private Pay Workflow

  • Rebilling (Claims that Never went to Payer)

  • Virginia Back-to-Back Visits

  • Virginia DMAS Forms

  • HHAX Set-up

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