This page contains answers to frequently asked questions on a variety of topics. You may select a topic or question below, or simply scroll down to read all of the questions and answers.

Important note: Answers to common questions are general guidelines for most health plans offered by Sentara Health Plans. While most of the answers apply to all plans offered by Sentara Health Plans, there may be some slight differences. Please refer to your plan materials or contact us for information.

General Questions

Yes, Sentara Health Plans is partnering with Availity to provide a robust payer-provider collaboration, reduce administrative burdens, eliminate manual processes, and provide self-service features.

If you are new to Availity Essentials, the Get Started page has an abundance of resources, including a recorded webinar that you can watch at your convenience. Once you have your Availity Essentials account, navigate to the “Help and Training” button in the upper right-hand corner of your home screen, then select “Get Trained” for additional training options.
You can access eligibility, benefits and claims information through  the Sentara Health Plans Provider Portal (available 24 hours a day) or by calling Provider Services.

If you need to confirm that you are a participating provider with Sentara Health Plans, you can use our directory to search for your provider profile. The "Plans Accepted" tab reflects the plans that you are currently contracted to accept as an in-network provider. You may also contact Provider Services for this information.

Medical Provider Services: 1-800-229-8822

Behavioral Health Provider Services: 1-800-648-8420

Sentara Community Plan Provider Services: 1-844-512-3172

Provider Updates/Changes

Please notify Sentara Health Plans as soon as possible of any changes to practitioner or practice information. Provider updates can take up to 30 days to process, so please submit your request at least 30 days prior to the desired effective date of your change to avoid interruption/loss of reimbursement.

You may submit your changes by completing the Provider Update Request Form.
No, but you must notify Sentara Health Plans within at least 90 days of leaving your previous practice. If notification is more than 90 days from the time you have left your previous practice, it may be necessary for you to go through the credentialing process again.

If you are moving to a solo practice or to a group who is not currently contracted with Sentara Health Plans, a new contract must be executed before you are able to render services under the new tax ID as an in-network provider. Providers can request to join the network at this link.

Please follow the steps outlined in the letter you received from HMS.

Credentialing/Plan Participation

Learn about joining our quality provider network.
The credentialing process typically takes approximately 90 days from the time we receive a complete application.
Yes. A completed contract is required before we can begin the credentialing process. If you are a new practitioner joining an already contracted group practice, no new contract will be necessary, and you will become party to your group's contract once your credentialing process is complete.
You will receive an email from your network educator welcoming you to the network, advising you of your Sentara Health Plans effective date.
If it has been more than 90 days since you submitted your complete application, and you have not been contacted by your network educator, you may contact Sentara Health Plans to inquire.

Contact Sentara Health Plans Credentialing at SHPCredDept@sentara.com.

Claims

Yes. Electronic submission is the preferred method of claims submission. Providers who file electronically benefit from documentation of claims transmission, faster reimbursement, reduced claims suspensions, and lower administrative costs.

Sentara Health Plans Medical Claims
PO Box 8203
Kingston, NY 12402

Sentara Behavioral Health Claims
PO Box 8204
Kingston, NY 12402

Sentara Health Plans allows 365 days for initial timely filing from the service date for all claims.
You can view claims status and view your payment remits on the Sentara Health Plans Provider Portal or by calling Provider Services.

Medical Provider Relations: 1-800-229-8822

Behavioral Health Provider Relations: 1-800-648-8420

Sentara Community Plan Provider Services: 1-844-512-3172
Reconsiderations, which is a provider written notification to dispute the processed claim payment/denial, can be submitted the following ways:
Via mail for Medicaid, Medicare, and Commercial lines of business: 
Medical: PO Box 5028, Troy MI 48007-5028
Behavioral Health: PO Box 1440, Troy MI 48099-1440

Via: Former Virginia Premier Portal for Medicaid and Medicare lines of business regarding dates of service: 
Beginning 1/1/2024 for Sentara Community Plan (formerly Optima Family Care/Optima Health Community Care) 
Beginning 5/1/2023 for Sentara Medicare (formerly Optima Medicare)

Corrections on paper can be submitted via mail using same address shown for original claim and reconsideration submissions. Corrected claims submitted on a paper CMS 1500 form should include original claim number and submission code “7” in field 22 to prevent misidentification of the corrected claim as a duplicate claim. For UB04 form corrections, the bill type should end in “7” with the original claim number showing in field 80 to prevent misidentification as a duplicate. Corrected claims on a CMS 1500 form can also be submitted electronically via legacy Optima Health Provider Connection portal if no attachments are being submitted. Corrected claims can also be submitted electronically. Please contact your clearinghouse to find out the specific requirements for submitting a corrected claim.

Medical Providers may submit corrected claims online through Provider Connection by selecting "Medical Claims," selecting the claim in question, and choosing the "Correct Claim" option. Providers are able to make corrections online to CPT coding, diagnosis, billed charges, quantity, and/or place of service.

Yes. Please complete and submit the EFT Application Form.

Direct deposit is safe, secure, and efficient. Funds are typically deposited 24 hours after payments are processed. Once enrolled for EFT, you will no longer receive paper remits, and can access your remits through the Sentara Health Plans Provider Portal or from your clearinghouse. 

Beginning on January 1, 2024, all Sentara Health Plans Medicare and Medicaid products will be processed on a single remit and an active PaySpan Account will be required. 

To start the PaySpan registration process, you may contact providersupport@payspan.com or call 1-877-331-7154, option 1 to obtain the registration codes and assistance with navigating the website.  You will receive the requisite registration code and can also request assistance with navigating the website. PaySpan is available Monday–Friday, 8 a.m.–8 p.m.
If you are not a participating provider with Sentara Health Plans, you will need to obtain your remits through your clearinghouse or by calling Provider Services. 
 

Medical Provider Relations: 1-800-229-8822

Behavioral Health Provider Relations: 1-800-648-8420

Sentara Community Plan Provider Services: 1-844-512-3172

Referrals

No. Sentara Health Plans does not require referrals.
Most of our members access the online provider directory to locate a provider best suited to their needs (location, office hours, areas of focus, populations seen, etc.). Maintaining an accurate directory profile, including your availability, specialties, and areas of focus is the best way to ensure members have the opportunity to access your services.

Please review your directory profile to ensure your information is accurate. If your provider directory profile is incorrect or needs to be updated, please contact your network educator as soon as possible.

Lab

Providers have the option of sending the patient with orders to a participating draw site. A list of draw sites is available by using the online provider directory. Members having surgery at a participating hospital can be sent directly to the admitting hospital with a prescription for pre-operative testing or a participating reference lab.
The In-Office Lab list includes a list of lab tests that the health plan will reimburse if performed in your office. In addition to this list, a limited number of additional lab tests may be performed in these specialists' offices: dermatology, OB/GYN, oncology, infectious disease, reproductive medicine, rheumatology, and urology. All PCP's and specialists (except those located in North Carolina) are restricted to the In-Office Lab list.

Pharmacy

You can review the formulary lists to identify what drugs are covered and which require prior authorization online. The Preferred or Standard Drug lists are provided to all participating providers at the time of contracting, as updated, and upon request. You can also see the provider manual for more detailed information. For questions or more specific information about a member's formulary, please call Sentara Health Plans Pharmacy Member Services at 1-800-741-9910.
You may contact Sentara Health Plans pharmacy Provider Services at 1-800-229-5522 option 3 for assistance or complete the appropriate drug pre-authorization form and fax to the health plan.
Some members are eligible to receive up to a 90-day supply of maintenance or long-term medications through our mail order pharmacy that will be delivered to their home.  Based on the member’s pharmacy benefits, they may receive a copay reduction for their 90-day supply. 

Providers or members can download and print our pharmacy mail order request forms. Providers may write up to a 90-day prescription for the member on the appropriate form or e-prescribe prescriptions to 1-888-637-5191.  

For more information about a member's mail-order pharmacy benefit, please call Sentara Health Plans pharmacy member services at 1-800-741- 9910.
Express Scripts® Pharmacy is Sentara Health Plans mail order pharmacy. Providers or members may contact Express Scripts Pharmacy, 24 hours a day, 7 days a week at 1-888-899-2653.

Appeals/Complaints

Please contact Provider Services or your Network Educator to discuss the matter. We will make every effort to resolve the matter quickly and informally. If, however, you are not satisfied with the outcome, you may contact Provider Services to initiate our provider appeal process.

Centipede/Non-Traditional Service Providers

Please contact Centipede Health Network at 855-359-5391 or via email at joincentipede@heops.com
You can contact Sentara Health Plans Community Plan Provider Services at 1-844-512-3172.

Provider Orientation/Education

Yes. Every participating provider is assigned a dedicated network educator for education and one on one support while doing business with Sentara Health Plans. Your network educator can provide in-office provider orientation and education for all participating providers (both new and established). Please contact network management at contactmrep@sentara.com to schedule an appointment with your network educator.

Providers