Updates

Effective May 31, 2026 (Professional) / June 30, 2026 (Facility), CPT code 88305 will now be considered as a part of the Daily Maximum Frequency editing for Sentara Health Plans. Sentara Health Plans will limit reimbursement of CPT 88305 based on a maximum number of units per member, per provider, per date of service. Services billed in excess of the established daily maximum units will be denied as not medically necessary or not separately reimbursable.

Effective June 15, 2026 (Professional) / July 15, 2026 (Facility), procedures billed with modifiers P3, P4 or P5 will be reimbursed based on the base units of the anesthesia procedure only; no additional reimbursement will be considered for these modifiers.

Effective August 28, 2026, Sentara Health Plans will no longer reimburse cpt codes 0054T-0055T, 20985, 61781-67183, and 69990, as they bundle into the primary surgical procedure.

Effective July 14, 2026 (Professional) / August 14, 2026 (Facility), Vitamin D testing requirements will follow the LCD set forth by Palmetto GBA/CMS, which requires specific ICD-10 diagnosis codes when billing with Vitamin D CPT procedure codes 82306, 82652, and 0038U.

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.

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.

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.

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.

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).

Provider payment processing is transitioning to the Zelis Payments Network.

OncoHealth will administer Sentara Health Plans' Oncology Benefits Management Program.

The Genetic Testing Management (GTM) program includes new and revised medical policies, a new authorization request process, guidelines, and consistent preservice reviews for certain genetic testing services that will be applicable to both ordering and rendering provider partners.