Appointment Access Standards
Medicaid
| Service | Sentara Health Plans Medicaid Standard |
| ServiceEmergency appointments, including Crisis Services | Sentara Health Plans Medicaid Standard Emergency appointments and services, including crisis services, must be made available immediately upon the Member’s request |
| ServiceUrgent/Symptomatic appointments | Sentara Health Plans Medicaid Standard Must be available as soon as the symptom demands but in no event more than 24 hours of the Member’s request. A symptomatic office visit is an encounter associated with the presentation of medical symptoms or signs, but not requiring care in an emergency room setting. |
| ServiceRoutine Primary Care | Sentara Health Plans Medicaid Standard Routine, primary care service appointments must be made within 30 calendar days of the member’s request. Standard does not apply to appointments for routine physical examinations, for regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every 30 days, or for routine specialty services like dermatology, allergy care, etc.) |
| ServiceMaternity Care – First Trimester | Sentara Health Plans Medicaid Standard Within 7 calendar days of request |
| ServiceMaternity Care – Second Trimester | Sentara Health Plans Medicaid Standard Within 7 calendar days of request |
| ServiceMaternity Care – Third Trimester | Sentara Health Plans Medicaid Standard Within 3 business days of requests |
| ServiceMaternity Care – High Risk Pregnancy | Sentara Health Plans Medicaid Standard Within 3 business days of high-risk identification, or immediately emergency exits |
| ServicePostpartum | Sentara Health Plans Medicaid Standard Within 60 days of delivery |
| ServiceMental Health Services | Sentara Health Plans Medicaid Standard As expeditiously as the member’s condition requires and within no more than 5 business days from Sentara Health Plan’s determination that coverage criteria is met |
| ServiceLTSS | Sentara Health Plans Medicaid Standard As expeditiously as the member’s condition requires and within no more than 5 business days from Sentara Health Plan’s determination that coverage criteria is met |
Commercial Plans - New
| Service | Sentara Health Plans Commercial Standard |
| ServiceEmergency appointments, including Crisis Services | Sentara Health Plans Commercial Standard Emergency appointments and services, including crisis services, must be made available immediately upon the member’s request |
| ServiceUrgent appointments | Sentara Health Plans Commercial Standard Within 24 hours of the member’s request |
| ServiceRoutine Primary Care | Sentara Health Plans Commercial Standard Routine, primary care service appointments must be made within 30 calendar days of the member’s request. Standard does not apply to appointments for routine physical examinations, for regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every 30 days, or for routine specialty services like dermatology, allergy care, etc. |
| ServiceMaternity Care – First Trimester | Sentara Health Plans Commercial Standard Within 7 calendar days of request |
| ServiceMaternity Care – Second Trimester | Sentara Health Plans Commercial Standard Within 7 calendar days of request |
| ServiceMaternity Care – Third Trimester | Sentara Health Plans Commercial Standard Within 3 business days of requests |
| ServiceMaternity Care – High Risk Pregnancy | Sentara Health Plans Commercial Standard Within 3 business days of high-risk identification, or immediately if an emergency exists |
| ServicePostpartum | Sentara Health Plans Commercial Standard Within 60 days of delivery |
| ServiceMental Health Services | Sentara Health Plans Commercial Standard Appointment availability must be no more restrictive than for medical conditions. |
| ServiceLTSS | Sentara Health Plans Commercial Standard As expeditiously as the member’s condition requires and within no more than 5 business days from Sentara Health Plan’s determination that coverage criteria are met. |
Medicare - New
| Service | Sentara Health Plans Medicare Standards |
| Service Urgently needed services or emergency | Sentara Health Plans Medicare Standards Immediately |
| Service Services that are not emergency or urgently needed, but the member requires medical attention | Sentara Health Plans Medicare Standards Within 7 business days |
| Service Routine and preventive care | Sentara Health Plans Medicare Standards Within 30 business days |
Contacts
- Provider Customer Service (Provider and member customer service numbers remain consolidated) - (800) 881-2166
- Transportation: (877) 892-3986
- Pharmacist Help Desk: (844) 604-9165
- Care Coordination: (866) 546-7924
- Network Educator: (product and service updates, escalations) contactmyrep@sentara.com
Corporate Address
U.S. Mail
Sentara Health Plans, Inc.
PO Box 66189
Virginia Beach, VA 23466
Overnight Mail
Sentara Health Plans, Inc.
1300 Sentara Park
Virginia Beach, VA 23464
Credentialing
Existing providers do not need to be credentialed again because of the merger. New providers seeking to join our network will initiate the process by submitting a Request for Participation form located on our website.
Email Addresses
All email addresses end “@sentara.com”
Kaiser Permanente
Kaiser Permanente member information will not be available on the Availity, Optima Health or Group Number VP secure portals. Attempts to search these members will produce a message letting the user know the member is part of the collaboration between Sentara Health Plans and Kaiser Permanente.
New Health Plan Names
Sentara Medicare Value (HMO)
Sentara Medicare Prime (HMO)
Sentara Medicare Savings (HMO)
Sentara Medicare Salute (HMO)
Sentara Medicare Engage - Diabetes and Heart (HMO C-SNP)
Sentara Community Plan (Medicaid/Cardinal Care)
Sentara Community Complete Select (HMO D-SNP)
Sentara Community Complete (HMO D-SNP)
Sentara Vantage (HMO)
Sentara POS
Sentara Plus (PPO)
Sentara Individual & Family Health Plans
Joining the Network
New groups joining the network will join under Sentara Health Plans and begin by submitting a Request for Participation located on the website.
If you are interested in joining the LTSS network, please contact Centipede for additional information.
To Join Our LTSS Network
CENTIPEDE Health Network
Phone: (855) 359-5391
Fax: (866) 421-4135
Email: joincentipede@heops.com
CENTIPEDE Credentialing
CENTIPEDE Health
P.O. Box 291707 Nashville, TN 37229
Facility and Ancillary Providers: Contact Network Management at (877) 865-9075 to inquire about the contracting process.
To add a new provider to a practice, please submit a Provider Update Form. Please review the provider credentialing requirements prior to completing your submission.
Medicare/DSNP Program Changes
Effective December 31, 2023, the CMS contracted plan Virginia Premier Advantage Elite (HMO D-SNP) will be sunset. All members in the Virginia Premier Advantage Elite plan will be auto-enrolled into the Sentara Community Complete Plan (HMO D-SNP), formerly known as Optima Community Complete. This means:
- All terms pertaining to Virginia Premier are no longer part of the Provider Agreement.
- The amended and restated Provider Agreement applies to all Members of Sentara Health Plans, regardless of their historical membership with Virginia Premier.
- Former Virginia Premier DSNP members will continue to be served under the program now known as Sentara Community Complete Select (HMO D-SNP).
- Impacted members will receive new membership cards before January 2024. Members will also get a new Member ID.
Remaining Informed
You will continue receiving the providerNEWs newsletter via email delivery. Current, and past editions of providerNEWs are available online for a limited time.
Verifying Eligibility with DMAS
Effective January 1, 2024, when determining eligibility via the DMAS provider portal, Sentara Health Plans members will be identified under Sentara Community Plans.
For dates of service before January 1, 2024, members will be identified under Optima Health or Optima (formerly Virginia Premier).