Updates

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.

OncoHealth will administer Sentara Health Plans (SHP) Oncology Benefits Management Program.

Effective January 1, 2025, Quest Diagnostics will become the exclusive independent laboratory vendor for Commercial and Government programs.

Department of Behavioral Health and Developmental Services (DBHDS) is requiring that providers of 23-Hour Crisis Stabilization services obtain one of the following licenses: (i) MH Center-Based Crisis Receiving Center for Adults (02-040) and/or MH Center-Based Crisis Receiving Center Children and Adolescents (02-041). Providers of 23-Hour Crisis Stabilization are required to do all the following actions by December 2, 2024.

Change In Enrollment Policy for Certain Dual Eligible Medicare-Medicaid Enrollees

Sentara Health Plans complies with CMS requirements for the use of modifiers JW and JZ on single-dose container drugs.

Sentara Health Plans does not cover general anesthesia when rendered in place of service 11 (office).

Sentara Health Plans will deploy an edit to review the inappropriate use of JW modifier (drug amount discarded/not administered to any patient). The JW modifier is only permitted to be used to identify discarded amounts from a single vial or single package drug or biological. It is inappropriate to append JW modifier to a multi-dose vial (MDV).

Effective September 1, 2024, Sentara Health Plans will increase commercial rates for ABA services to align with DMAS. Our contracting processes were modified to automatically apply rate changes as they are released.

Authorization requirements for Electroconvulsive Therapy (ECT) 90870 was removed. Providers should provide the service to members and file a claim for reimbursement

Modifier 51 is used to indicate multiple procedures other than evaluation and management (E/M) services performed by the same provider on the same day. The Modifier 51 policy edit will be effective September 1, 2024.

On September 1, 2024, Sentara Health Plans will deploy a new edit on telemonitoring codes that includes a description that defines a time period where a code can only be billed within the designated time requirements.

Sentara Health Plans policies align with the Notice of Medicare Non-Coverage and actions required to remain compliant with the Centers for Medicare & Medicaid Services (CMS). Sentara Medicare Utilization Management (UM) would like to partner with our providers to ensure we are adhering to CMS regulations.

The Two-midnight Benchmark, Medical Necessity Criteria

Effective July 1, 2024, Sentara Health Plans will no longer require prior authorization for: • Mental Health Case Management (H0023) • Substance Use Case Management (H0006)