CommercialPrior AuthHigh impact
Summer 2025 Authorization Updates
Sentara Health Plans·Psychiatry, General Surgery, Bariatric Surgery·Prior Authorization
Effective date
Jul 1, 2025
We identified it
Aug 20, 2025
Summary
Sentara Health Plans has updated 28+ prior authorization policies effective July 1, 2025, with major changes concentrated in behavioral health substance abuse treatment (ASAM levels), ambulatory devices/DME, and bariatric surgery coverage. Most changes involve criteria simplification for Medicaid programs, while some policies are being archived for Commercial plans. Billing teams must immediately review affected codes and update prior authorization requirements in their systems.
Action Required
By June 30, 2025: Billing team must update prior authorization workflows and system rules for all affected codes listed above. (1) For Medicaid plans: Review simplified ASAM criteria on sentarahealthplans.com behavioral health policy page and update authorization decision trees for codes H2036, H0015, S0201, H2034, H0010, H0011, and H0040. (2) For Commercial DME claims: Update authorization requirements for ambulatory device codes E0117, E0118, E0152, E1399, E3200 per new DME 40 policy. (3) For Commercial/Medicaid bariatric surgery: Archive Surgical 32 policy for these plans; do NOT submit prior auth requests for codes 43633, 43644, 43645, 43659, 43770-43775, 43842-43848, 43886-43887, 4388 on Commercial/Medicaid effective 7/1/2025. (4) For Medicare bariatric: Continue using NCD 100.1 and LCD L34576 (no change). (5) For Assertive Community Treatment (ACT): Update Medicaid prior auth criteria for codes 90791, 90792, H0040. Providers and front desk staff must not submit prior authorizations for archived policies. Failure to comply will result in claim denials and rework. Update encounter forms and authorization checklists to reflect new policy status by June 30, 2025.