CommercialCoverageHigh impact
Medical and Clinical Policy Updates - Effective July 1, 2026
Sentara Health Plans·General Surgery, Cardiology, Cardiothoracic Surgery +11 more·Medical Policy
Effective date
Jul 1, 2026
We identified it
Apr 13, 2026
Summary
Sentara Health Plans has updated 53 medical policies effective July 1, 2026, affecting surgical procedures, durable medical equipment, behavioral health/substance abuse treatment, cardiac rehabilitation, and other services. Most policies were reviewed for continued applicability; several were revised (including gastrointestinal procedures, BPH treatments, prescription digital therapeutics, wheelchairs, chiropractic services, and ambulatory devices). One policy (TIPSS) was archived and will no longer be covered. Billing teams must verify coverage requirements and prior authorization rules for affected services before the effective date.
Action Required
By June 30, 2026: (1) Billing team must access the complete policy details at sentarahealthplans.com and pal.sentarahealthplans.com to identify specific coverage changes and prior authorization requirements for each updated policy. (2) Update billing system rules and Prior Authorization List (PAL) requirements to reflect all 53 policy changes. (3) For the archived Medical 256 TIPSS policy, immediately flag this procedure as non-covered effective July 1, 2026—claims submitted after this date will be denied. (4) For revised policies (Surgical 205, Surgical 83, Medical 259, DME 28, Medical 182, DME 30, DME 40), verify if prior authorization or documentation requirements have changed and update encounter forms and system workflows accordingly. (5) For behavioral health policies (BH 06-59, all ASAM levels), confirm which concurrent vs. initial admission scenarios require prior auth and update substance abuse treatment billing processes. (6) Providers and coding staff should review updated policies before billing; failure to comply with new requirements will result in claim denials. (7) Communicate policy changes to all clinical departments, especially surgery, orthopedics, cardiac rehabilitation, behavioral health, and DME teams.