CommercialCoverageHigh impact
Medical and Clinical Policy Updates - Effective May 1, 2026
Sentara Health Plans·General Surgery, OB-GYN, Cardiothoracic Surgery +7 more·Medical Policy
Effective date
May 1, 2026
We identified it
Feb 12, 2026
Summary
Sentara Health Plans has updated 22 medical policies effective May 1, 2026, with changes spanning surgical procedures, imaging services, DME, and clinical treatments. Key changes include: 12 policies archived (no longer covered), 7 policies revised (coverage criteria or requirements changed), and 3 policies reviewed (clarification without coverage changes). Billing teams must immediately audit claims for archived policies and stop billing those services; for revised policies, documentation and authorization requirements may have changed.
Action Required
By April 15, 2026: Billing team must cross-reference all 22 policy changes against your current fee schedules and prior authorization lists. CRITICAL ACTIONS: (1) STOP BILLING all archived policies effective 5/1/2026 (Surgical 86, OB 10, Imaging 24, Medical 139, Surgical 02, Medical 328-Commercial only, Medical 254, Medical 250, Medical 252, Surgical 111, Surgical 82); (2) For revised policies (Surgical 05, Surgical 235, Medical 13, Medical 81), contact Sentara at pal.sentarahealthplans.com or sentarahealthplans.com to obtain updated clinical criteria and prior authorization requirements; (3) Update billing system to flag claims for reviewed policies (OB 10, Medical 337, DME 26, Surgical 03, Medical 246, Surgical 108) and ensure providers are documenting medical necessity per new standards; (4) Identify all claims submitted in past 90 days for archived procedures and prepare for potential denials or demand letters—contact Sentara's Provider Relations to confirm claims adjustment protocol; (5) Train front desk and providers on the new policy landscape by April 30, 2026. Failure to comply will result in claim denials, recoupments, and potential compliance violations. Reference: sentarahealthplans.com and pal.sentarahealthplans.com for detailed policy language.