Accessing the Prior Authorization List (PAL) for Medicaid and Medicare
The new Prior Authorization List (PAL) is available to determine authorization requirements for Medicaid and Medicare members. It is also accessible at pal.sentarahealthplans.com (be sure to bookmark it) or through the Availity portal payer space. Select the member’s current plan and date of service to begin your search. The tool can be used to search by procedure code or full/partial code description.
Existing Authorizations: ALL authorizations that are approved and in progress will be honored, including those submitted to the former Virginia Premier DSNP program. The guidelines supporting the authorizations for authorized services will remain the same. New authorization numbers will not be created.
New Authorizations: New authorizations are triggered by member eligibility. Please use the Sentara Health Plans authorization process.
Authorizations Temporarily Not Viewable Sentara Health Plans is undergoing a system conversion for our Medicaid line of business. Authorization requests submitted between November 22, 2023 to December 6, 2023 may not show in the provider portal. We will continue to fax and mail determination letters to providers and members within our standard processing timeframe. We will continue to respond to urgent authorizations by fax. Outpatient providers will be required to bill span dates crossing over 1/1/24 separately, with service dates prior to 1/1/24 billed distinctly from those following 1/1/24.
Providers should search by member vs. authorization number.
• After January 1st providers will be able to view authorizations online through the legacy Optima portal Provider Connections.
• Continue to submit authorization requests via the existing Sentara Health Plans process.
• There will not be any disruption to our members’ care and claims will still be processed accordingly.
• If you have any questions about your authorization, please call provider customer service at (800) 881-2166 if you have questions or need an immediate update on your request.
Doula Program Fax Numbers – New
833-666-0706 – toll free
Medical/LTSS Utilization Management Phone and Fax Lines Effective January 1, 2024
Utilization management is aligning according to lines of business, i.e., Medicaid, Medicare and commercial.
Private Duty Nursing
Effective 1/1/24, these authorizations will only be approved for 90 days.
PDN RN Nursing Services = T1002 (billed hourly)
PDN LPN Nursing Services = T1003 (billed hourly)
Congregate RN Nursing Services = T1000 U1 (billed hourly).
Congregate LPN Nursing Services = T1001 U1 (billed hourly).
|Request Types Medicaid OP/DME Fax
|Fax Number 757-963-9623 / 844-348-3720
|Request Types Medicaid Urgent Fax
|Fax Number 757-837-4704 / 844-857-6409
|Request Types Medicaid Drugs Fax
|Fax Number 757-579-8625 / 844-305-2331
|Request Types Medicare OP/DME Fax
|Fax Number 757-963-9625 / 844-220-9566
|Request Types Medicare Urgent Fax
|Fax Number 757-963-9626 / 844-220-9673
|Request Types Medicare Drugs Fax
|Fax Number 757-963-9624 / 844-895-3232
|Request Types LTSS UM Auths Fax
|Fax Number 757-837-4702 / 844-828-0600
|Request Types LTSS UM New Waivers Fax
|Fax Number 757-837-4700 / 844-857-6408
|Request Types Medicare IP Fax
|Fax Number 757 500-4835/833-459-0784
|Request Types Medicare POSTACUTE Fax
|Fax Number 757 470-5941/ 833-459-0783
|Request Types Medicaid IP Fax
|Fax Number 757-963-9621 / 844-220-9565
|Request Types Medicaid POSTACUTE Fax
|Fax Number 757-963-9622 / 844-220-9572
|Request Types GOVT NEWBORN ENROLLMENT Fax
|Fax Number 757-837-4701 / 844-883-6064
|Request Types Behavioral Health Inpatient and Crisis Services UM Fax
|Fax Number 757-963-9619 / 844-348-3719
|Request Types Mental Health Services Fax
|Fax Number 757-963-9620 / 844-895-3231
|Request Types ARTS Fax
|Fax Number 844-366-3899
- In office Lab List
- Formularies and Drug Lists
- Medical Authorizations and Reconsiderations
- Prescription Drug Authorizations
Your experience with Jiva will remain the same. Explore Jiva resources.
Prior Authorization List (PAL) Medicaid and Medicare Limits
The Sentara Health Prior Authorization List (PAL) is being updated on January 1, 2024, for Medicaid and Medicare lines of business, and changes in authorization requirements are updated and available on our website. Providers will not be required to obtain an authorization for certain medical supplies or services when the request does not exceed certain limits. Details regarding limits will be noted in the Exceptions column of the Prior Authorization List. The PAL tool will be accessible through the Availity Payer Space.
Example 1: Monthly Limitations
|HCPC Code A4230
|Description Infusion insulin pump non needle cannula type
|Authorization Required YES
|Exceptions NO AUTH REQUIRED UNTIL DMAS LIMIT IS REACHED
In the example above, the provider may submit claims for 16 infusion insulin pump non needle cannulas per month without needing an authorization for payment as the DMAS limit for this supply is 16 units per month. DMAS limits may be found under Appendix B of the Medicaid Durable Medical Equipment Supplies and Listing (https://www.dmas.virginia.gov/for-providers/long-term-care/services/durable-medical-equipment/)
Example 2: Age Limitation
|DescriptionAdd to low ext orthosis non-corrosive finish
|Authorization Required YES
|ExceptionsNO AUTH REQUIRED UNDER AGE 21
In this example, the provider may submit a claim for this supply without the need for an authorization for payment if the member was under the age of 21 years on the date of service. Authorization will be required for this supply for any member over the age of 21 years on the date of service.
Example 3: Physical, Occupational, and Speech Therapy
|Descriptionappl modality 1/> areas traction mechanical
|Authorization Required YES
|ExceptionsNO AUTH REQUIRED UNTIL 64 UNITS ARE EXCEEDED
In this example, the provider may submit claims for up to 64 units of service code 97012 (appl modality 1/> areas traction mechanical) in a rolling 12-month period. After the 64 units, the provider will be required to obtain an authorization for continued services. This limit is cumulative across providers. If a member had received this service during the same 12-month period from another provider, this would count toward the 64 unit limit. Providers may be required to obtain an authorization for services if the member had received the same service previously from another provider during the same 12-month period.