Summary
Aetna Better Health of Virginia sets the rules for providers who serve its Virginia Medicaid managed care members for the contract year July 1, 2026 through June 30, 2027. The rules cover claim filing, with claims due within 365 days from the date of service, along with prior authorization, member eligibility verification, claim coding and form requirements, and credentialing. Claims are rejected when an effective Medicaid ID cannot be found on the Virginia MES registry.
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What to do
Action · 14 steps
01Billing team: Verify each member's eligibility before delivering nonemergent covered services, because providers are not reimbursed for services to members who lost eligibility.
02Obtain prior authorization before rendering services that require it; unauthorized services will not be reimbursed, and authorization is not a guarantee of payment.
03Make sure dates of service on the claim fall within the prior authorized service date range, since dates outside that range may result in denials.
04Notify Provider Relations of covering providers before any authorized services are provided, since failure to do so may result in claim denials.
05File new claims within 365 days from the date of service, submit adjustments within 365 days from the adjudication decision, and submit coordination of benefits claims within 365 days from the primary carrier remittance advice date with a copy of the primary remittance advice attached.
06Enter the billing provider NPI in Box 33A and billing provider taxonomy in Box 33B of the CMS-1500, the billing NPI in Block 56 of the UB-04, and the rendering NPI in the bottom half of Box 24J.
07Claims are rejected when the taxonomy code does not match the Virginia MES file for the NPI on the claim, or when it is omitted, so confirm enrollment and taxonomy before billing.
08Use valid ICD-10 codes coded to the highest specificity (seventh digit where applicable), valid CPT, HCPCS and revenue codes, and a valid place of service in Block 24B on each CMS-1500 line, since claims with nonstandard codes or modifiers are returned.
09Do not unbundle procedures or break out bilateral procedures when one code is appropriate.
10Attach an itemized billing statement to claims billed over $50,000.00, or the claim will be denied.
11Bill interim claims with patient status 30 and at least 60 days billed.
12For youth sport physicals for members aged 7 to 18, bill diagnosis code Z02.5 with CPT code 99429, once per year on an annual basis, not per calendar year.
13Do not bill members beyond their cost-sharing liability shown on the remittance advice.
14Notify Provider Relations of demographic or payment data changes at least sixty days before the effective date of change.
Codes mentioned
99429Z02.5
Original notice
Provider manual
aetnabetterhealth.com · Always check the source before changing claims.