Medicare AdvantagePrior AuthHigh impact
Medical and Clinical Policy Updates - Effective April 1, 2026
Sentara Health Plans·Cardiology, General Surgery, Gastroenterology +5 more·Medical Policy
Effective date
Apr 1, 2026
We identified it
Jan 12, 2026
Summary
Sentara Health Plans is implementing multiple medical policy updates effective April 1, 2026, including revisions to prior authorization procedures, adoption of new advanced imaging guidelines, archival of the Genetic and Molecular Testing policy (with transition to OncoHealth and Avalon vendors), and policy updates across observation care, lumbar laminectomy, TIPSS, prescription digital therapeutics, mechanical stretching devices, and radiation treatment. Additionally, effective February 1, 2026, Medical Policy 34 will be archived with authorization responsibilities transitioning to specialized vendors.
Action Required
By March 15, 2026: Billing and clinical teams must prepare for multiple workflow changes. (1) Review all revised medical policies (Medicare 350, Surgical 121, Medical 256, Medical 259, DME 31, Medical 350 Radiation) at sentarahealthplans.com and update encounter templates, prior authorization triggers, and billing rules accordingly. (2) Implement new Evolent Advanced Imaging Guidelines for all imaging requests (note: CCTA policy 7275 has additional criteria requiring documentation that results are necessary for clinical decision making). (3) Effective immediately (February 1, 2026): Update authorization routing for Genetic and Molecular Testing—direct oncology cases to OncoHealth (oncohealth.us), nononcologic cases to Avalon (fax 813-751-3760, call 844-227-5769, or PAS portal), and all other requests through MCG Provider Portal. (4) Update prior authorization lists in billing software by referencing pal.sentarahealthplans.com. (5) Train billing staff on new vendor contact procedures for genetic testing to prevent claim delays and denials. (6) By April 1, 2026: Ensure all systems reflect the April 1 policy effective dates. Failure to implement prior authorization changes will result in claim denials; routing genetic testing requests to incorrect vendors will delay authorization.