Updates

Effective October 23, 2025, Sentara Health Plans announced availability of the redesigned Provider Reconsideration Form to improve efficiency and ensure accurate routing of all requests.

As part of our ongoing commitment to clinical excellence and member-centered care, Sentara Health Plans Behavioral Health Utilization Management (SHP BH UM) is refining our review process for ARTS authorization requests. These enhancements are designed to support more precise alignment of services with member needs, while continuing the high standards of review we have always upheld.

Commercial Behavioral Health authorization fax numbers and forms for urgent and non-urgent requests.

Commercial Behavioral Health authorization fax numbers and forms for urgent and non-urgent requests.

Government Behavioral Health authorization fax numbers and forms for urgent and non-urgent requests.

Government Behavioral Health authorization fax numbers and forms for urgent and non-urgent requests.

Sentara Health Plans will apply a claims edit to deny radiology procedure codes requiring anatomical modifiers when the modifier is not submitted on the claim. Without the proper anatomical modifier applied to the procedure code, there is a risk of duplicate claims payment, incorrect procedure-to-procedure bundling, incorrect frequency limitations, and unnecessary medical record review.

Sentara Health Plans will apply a claims edit to deny radiology procedure codes requiring anatomical modifiers when the modifier is not submitted on the claim. Without the proper anatomical modifier applied to the procedure code, there is a risk of duplicate claims payment, incorrect procedure-to-procedure bundling, incorrect frequency limitations, and unnecessary medical record review.

MS DRG 870 reports claims for septicemia or severe sepsis with mechanical ventilation greater than ninety-six hours. The edit will deny claims for MS DRG claims when the discharge status is not equal to (02,05,30,82,85) and reports with inpatient procedure code 5A0955A and the length of stay less than 96 hours.

MS DRG 870 reports claims for septicemia or severe sepsis with mechanical ventilation greater than ninety-six hours. The edit will deny claims for MS DRG claims when the discharge status is not equal to (02,05,30,82,85) and reports with inpatient procedure code 5A0955A and the length of stay less than 96 hours.

Sentara Health Plans will deny claim lines when two or more of the service codes listed below are billed by the same provider on the same date of service including when modifier 59 is applied.

Sentara Health Plans will deny claim lines when two or more of the service codes listed below are billed by the same provider on the same date of service including when modifier 59 is applied.

Effective August 1, 2025, Sentara Health Plans will be deploying an edit that reviews surgical procedures on the foot and toes (code range 28001-28899*) and the hand and fingers (code range 26010-26989*) when they are not reported with the appropriate anatomical modifier.

Effective August 1, 2025, Institutional providers should not have to report on the usage of a no cost item. However, claims providers may be required to bill a no cost item due to claims processing edits that require an item (even if received at no cost) to be billed along with an associated service.

Effective August 1, 2025, Institutional providers should not have to report on the usage of a no cost item. However, claims providers may be required to bill a no cost item due to claims processing edits that require an item (even if received at no cost) to be billed along with an associated service.

Any notice, request, instruction or other document or correspondence required to be given under the Provider Agreement, if sent by registered mail, overnight delivery or certified mail, or return receipt requested, must be mailed to the following address: Vice President, Network Management Sentara Health Administration, Inc. 1300 Sentara Park Virginia Beach, Virginia 23464.

Any notice, request, instruction or other document or correspondence required to be given under the Provider Agreement, if sent by registered mail, overnight delivery or certified mail, or return receipt requested, must be mailed to the following address: Vice President, Network Management Sentara Health Administration, Inc. 1300 Sentara Park Virginia Beach, Virginia 23464.

Effective March 31, 2025, health coaching, authorization support for post-acute care, and sleep services performed by CareCentrix® will be transitioned to Sentara Health Plans. The network for Home Infusion services will transition from CareCentrix network to the Sentara Health Plans network.

According to the ICD-10-CM manual guidelines, some diagnosis codes indicate laterality, specifying whether the condition occurs on the left or right, or is bilateral. The diagnosis-to-modifier comparison assesses the lateral diagnosis associated with the claim line to determine if the procedure modifier matches the lateral diagnosis.

Diabetic shoes and inserts are covered expenses for adults over the age of twenty-one (21) when medically necessary and submitted with an ICD-10 code for Diabetes (ICD-10 E08.00-E13.9).