Spring 2026 Medical and Clinical Policy Updates

REQUIREMENTS: 1. By April 15, 2026: Billing team and clinical leadership must review the complete policy text for each policy listed in the newsletter at sentarahealthplans.com to identify which archived, revised, and reviewed policies directly affect services your practice provides. 2. By April 20, 2026 (for May 1 effective date policies): For all policies marked as "Revised" or "Archived" that affect your practice: - Document the specific changes in each policy - Identify associated CPT/HCPCS/ICD-10 codes - Update billing system rules and edits - Update prior authorization requirements (reference pal.sentarahealthplans.com for current Prior Authorization List) - Modify encounter forms and clinical documentation templates 3. By May 15, 2026 (for June 1 effective date policies): Repeat step 2 for February-reviewed policies. 4. By June 15, 2026 (for July 1 effective date policies): Repeat step 2 for March-reviewed policies. 5. Immediately: Identify behavioral health services in your practice (if applicable). The March review includes 32 ASAM-level substance abuse treatment policies—verify coverage status for each level (Initial vs. Concurrent) across adult and adolescent populations in your Medicaid plans. 6. Update provider-facing tools: - Revise fee schedules for revised policies - Communicate archived policies to providers (claims will be denied) - Update superbills and order entry systems 7. Consequences: Claims for archived services will be denied. Claims for revised services submitted without updated prior authorization requirements will be denied. Providers must be informed of coverage changes before service delivery.