Provider News

In the past few months, Sentara Health Plans has implemented several system changes to improve the way we do business with you as a provider. We are seeing some growing pains along the way, but we believe the end result will be improved functionality for all.

This week, we are sharing the following provider updates — Managed Behavioral Health and Health Equity Full Accreditation Awarded ,Hampton Roads Sanitation District Joins Sentara Health Plans, New Paper Claims Vendor – Electronic Submission Encouraged, Provider Satisfaction and Access Surveys Scheduled to Begin Next Month, Managed Behavioral

As part of Sentara Health Plans’ ongoing commitment to providing convenient, self-service tools to the provider community, we encourage the use of the authorization capabilities within the secure provider portal.

This week, we are sharing the following provider updates — New Resources Available, Scheduled Jiva Outage, Sentara Health Plans Roundtable Meetings, Three-Day Payment Window Policy, Payment Policies in Availity, New Paper Claims Vendor

This week, we are sharing the following provider updates — Update: Secondary Claims Denial, Long Term Support Services Claims Processing Issues

This week, we are sharing the following provider updates — Availity for claims submission during Change Healthcare outage, Updated Medicaid Provider Manual, Self-service password reset process, Educational opportunities

This week, we are sharing the following provider updates — Access to the Former Virginia Premier Portal Restored, Self-Service Password Reset Process, NIA - Scheduled Outage, Percutaneous Coronary Procedures: Modifiers Required

On Wednesday, February 21, Sentara Health, for the protection of our consumers and systems, disconnected inbound and outbound transactions from Change Healthcare, a subsidiary of UnitedHealth Group, following reports of a cyber incident with the healthcare technology company. Health systems, hospitals, and pharmacies nationwide are being impacted by this disruption.

On Wednesday afternoon, Sentara Health Plans was alerted that Change Healthcare experienced a cyber security incident. Due to the nature of this threat, we made the decision to disconnect inbound and outbound transactions from Change Healthcare.

This week, we are sharing the following provider updates — Remittance Viewing in Availity Essentials, Modifier 25 Update, Secondary Claims Denial Update, Easing Administrative Requirements for ACT, FFT, and MST Services, Important Reminder – New Paper Claims Mailing Address, Provider Quality Care Workgroup, Register for Our Upcoming Webinars

Modifier 25 Payment Policy Reminder- Addendum Regarding Identified Processing Issue

When a preventive examination and a problem-oriented E/M service are reported on the same day for the same patient, the problem-oriented E/M service is reimbursed at 50% of the allowed amount regardless of the code appended with modifier 25.

As part of our claims platform migration work, we have identified that secondary enrollment records were not populated correctly. This caused a claims routing error resulting in unpaid secondary claims for dual aligned members under our former Optima Health plan with 2023 dates of service.

This week, we are sharing the following provider updates — see below to learn more. NIA Authorization Approvals, Filing Requirements: Rendering and/or Billing Provider, Provider Quality Care Workgroup, Register for Our Upcoming Webinars

Welcome to Sentara Health Plans, 2024 Welcoming Baby Update, Dr. Melvin T. Pinn Quality Excellence Award, 2024 Healthy Rewards, Time To Prepare for HEDIS®️ Medical Record Review, New Sentara Health Plans Provider Web Portal, Authorization Updates, Pharmacy Formulary Updates, Register for Our Upcoming Webinars, and more.

This week, we are sharing the following provider updates — see below to learn more. Provider Quality Care Workgroup, Model of Care Annual Review and Attestation Requirement, Accessing the Prior Authorization List (PAL) for Medicaid and Medicare Reconsiderations: Former Virginia Premier Portal Registration, Sentara Health Plans Operations Effective January 1, 2024, W-9 Requirement, Chronic Conditions, Special Needs Plans (C-SNP) Accessing Sentara Health Plans in Availity

Verifying Member Eligibility for Sentara Health Plans. Please note the clarification regarding member ID cards from the provider alert emailed to providers on January 8, 2024. Previous provider alerts can be found on our website.

Welcome to Sentara Health Plans. As of January 1, 2024, Optima Health and Virginia Premier consolidated under our new name, Sentara Health Plans. Despite the name change, our dedication to delivering top-quality healthcare remains unwavering.

Availity Essentials Update - Sentara Health Plans (Optima Health) previously communicated our partnership with Availity Essentials beginning on January 1, 2024.

You are receiving this email because one or more of your patients was identified as an affected Medicare member who received an incorrect ID card effective November 1, 2023, and December 1, 2023, and incorrectly had 2024 copays listed.

This week, we are sharing the following provider updates — Attend a Sentara Health Plans Full Integration Webinar, New Sentara Health Plans Provider Web Portal, Prior Authorization Changes for Medicare Part D.

We understand you submitted a claim through the Virginia Premier Health Plan (VPHP) portal in the last 12 months. This functionality will no longer be available on the VPHP portal, but will be available on the Availity portal on January 1, 2024.

This week, we are sharing the following provider updates — Verifying Eligibility With DMAS, NIA Issues.

This week, we are sharing the following provider updates — Payment and Reimbursement Policy Updates,Optima Health Vendor Partnerships, Authorization Requirement Update, Reminder: Medicaid Authorizations Update, Elective Authorization Requests for Hysterectomies – Medicaid, Authorizations Temporarily Not Viewable: Date Span Correction

This week, we are sharing the following provider updates — see below to learn more. Provider Connection - Member ID Field Update, Reminder: Medicaid, Authorizations Update, Provider Manuals, Avalon Provider Training Opportunities

Optima Health is undergoing a system conversion for our Medicaid line of business. Authorization requests submitted between November 22, 2023 to December 6, 2023, may not show in the provider portal, but this does not indicate that the plan has not received or reviewed them.

As of November 1, 2023, Optima Health payment policies are accessible through Provider Connection, our secure portal. The policies, stored in Compliance 360, explain acceptable billing and coding practices to equip you for accurate claims submission. We will inform you as new policies are published.

At the end of 2023, the Optima Health and Virginia Premier brands will retire and unify under Sentara Health Plans. Our growth affords us the opportunity to innovate and adapt to align with best practices in the industry, as well as partner with you to ensure our shared customers receive the care they need, when they need it.

As valued partners in healthcare, we are excited to share upcoming changes that are geared towards enhancing the quality of care for our shared patients.

Featuring: Introducing Sentara Health Plans, Coming Soon: Sentara Health Plans Partners With Availity; Member Accommodations and Communication Service, Welcoming Baby Program, Focus HEDIS Measures, Authorization Requirements, and more.

Virginia’s Department of Medical Assistance Services (DMAS) has shared information regarding Provider Services Solution (PRSS) guidelines for subunits.

Positive and/or lateral prior authorization updates, effective October 2, 2023, will be listed on optimahealth.com on Thursday, October 5, 2023.

This week, we are sharing the following provider updates — see below to learn more. Inappropriate Use of Modifier 57 • Attention: OB/GYN Providers - Doula Balance Billing • Imaging and Cardiac Services Program • Medicare Data and Eligibility Verification Outage • New Password Requirements

As of September 13, 2023, we will move from an 8-character network password to a 12-character network password policy. The policy will take effect on the user’s next required password rotation and includes Provider Connection, our secure portal.

In an effort to protect the Sentara Health enterprise and our consumers from cyber security threats, we are continually evaluating opportunities to advance our internal and external cyber security capabilities.

Additional webinars have been scheduled for September 13 and 20 at 10 a.m. Register now for the session most convenient for you, or learn at your own pace by viewing the slide presentation.

Featuring: Optima Health Welcomes Former Virginia Premier Providers, Optima Health Appointment Standards, Where To Go for Urgent Care Needs, Pharmacy Travel Essentials, Statin Use in Persons With Diabetes (SUPD), COVID-19 Updates and more.

Changes in the Medicare Part B program will improve access to high quality, affordable biosimilars for people with Medicare as well as impose a $35 per month cost-sharing cap on insulin used in DME pumps.

Changes in the Medicare Part B program will improve access to high quality, affordable biosimilars for people with Medicare as well as impose a $35 per month cost-sharing cap on insulin used in DME pumps.

Optima Health launched its new claims platform on May 1, 2023, for Medicare claims only at this time. As part of this change, providers will have all EFT/ERA issued through PaySpan^®.

An updated Optima Health Provider Manual will be released later this month.

Optima Health has a new repository for clinical policies.

Optima Health Plan will assume agreements with Virginia Premier Providers on July 1.

Additional information to help you prepare for upcoming changes.

On February 1, we notified you of a change to the system we use to process Medicare claims. To ensure a smooth transition for all our providers, we have extended our implementation date from April 1, 2023, to May 1, 2023. Please see details below to learn more.

We previously announced that, effective April 1, 2023, we would no longer require an authorization for the first 15 visits for outpatient physical therapy (PT), occupational therapy (OT), and speech therapy (ST) for MAPD and DSNP members.

Optima Health partners with LexisNexis. Unverified provider information cannot be included in our online directory.

Starting in March 2023, Virginia will begin reviewing members’ health coverage to make sure they still qualify; however, members will not lose coverage prior to April 30, 2023.

Optima Health is pleased to announce the selection of VSP®️ Vision Care to manage routine eye exams and materials benefits for commercial, Medicare, and Medicaid product lines, beginning January 1, 2023.

Sentara Healthcare, one of the largest not-for-profit integrated health care delivery systems in the U.S. Mid-Atlantic region, has finalized the transaction with SantaFe HealthCare, Inc., for ownership of AvMed, Inc., a not-for-profit health plan in Florida.