Vendor Partnerships

AccordantCare

The AccordantCare™ Program is designed to help members find the answers and support they need to manage their health care needs and maximize their overall health status. This specialized education and support program is offered to members with the following conditions:

Amyotrophic Lateral Sclerosis (ALS) • CIDP (Chronic Inflammatory Demyelinating Polyradiculoneuropathy) • Crohn’s Disease • Cystic Fibrosis • Dermatomyositis • Epilepsy (Seizures) • Gaucher Disease • Hemophilia • Hereditary Angioedema • Human Immunodeficiency Virus (HIV) • Multiple Sclerosis • Myasthenia Gravis • Parkinson’s disease • Polymyositis • Rheumatoid Arthritis • Scleroderma • Sickle Cell Disease • Systemic Lupus Erythematosus (SLE or Lupus) • Ulcerative Colitis

Members are identified via claims data analysis and individual case management referrals. Once identified, eligible members will receive introductory mailings and calls to enroll in the program. AccordantCare will also notify providers of program enrollment and ongoing collaboration on member’s plan of care.

Avalon

Routine Testing Management (Laboratory) 

Avalon provides Routine Testing Management (RTM) services. RTM, an automated review of high-volume, low-cost laboratory tests, provides consistent application of laboratory policies while remaining provider and member friendly. 

Laboratory services reported on claims will be reviewed for adherence and consistency with Sentara Health Plans laboratory policies and guidelines. Avalon will also ensure alignment with industry standardized rules, including (but not limited to) evaluating services for being experimental and/or investigational and meeting clinical appropriateness for patient demographics. Additionally, codes reporting multiple units billed will be reviewed for appropriateness to code-specific unit allowances under Sentara Health Plan’s laboratory policies and guidelines.

 
Avalon’s automated policy enforcement will be applied by Sentara Health Plans to claims with laboratory services provided in office, hospital outpatient and independent laboratory locations. Laboratory services, tests and procedures provided in the emergency room, hospital observation and hospital inpatient settings are excluded from this program. Avalon’s automated policy enforcement is designed to ensure the consistent application of Sentara Health Plan’s laboratory policies and guidelines to claims with laboratory services.

Policies and guidelines

Avalon Provider Training Opportunities

Avalon provides Routine Testing Management (RTM) services. RTM, an automated review of high-volume, low-cost laboratory tests, provides consistent application of laboratory policies while remaining provider and member friendly. Avalon will be hosting training sessions early next year to introduce new providers to the program and processes.  Existing users are welcome to attend as well.  The meeting will be facilitated through Microsoft Teams and you may join on your computer, mobile app or room device.

Carelon

Medical Oncology 

Radiation Oncology

Evolent

NIA, our Medical Specialty Solutions program vendor, is now Evolent.  Services include prior authorization of nonemergent, advanced outpatient imaging and some cardiac services.
The decision to implement this program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services. 

Under terms of the agreement, Sentara Health Plans will oversee the Evolent program and remain responsible for claims adjudication. Evolent will manage the following services: 
 
1. CT/CTA
2. CCTA
3. MRI/MRA
4. PET Scan
5. Myocardial Perfusion Imaging
6. MUGA Scan
7. Stress Echocardiography 
8. Echocardiography
9. Cardiac Implantable Devices (defibrillator, pacemaker, resynchronization therapy)
10. Left Heart Catheterization 

Please note the following:

Updated 5/7/24

Modivcare – New

Performant - New