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Medical and Clinical Policy Updates - Effective October 1, 2026
Act
by Sep 15, 2026
Effective date
Oct 1, 2026
Identified
Jul 14, 2026
Summary
Effective October 1, 2026, Sentara Health Plans is implementing multiple coverage and prior authorization changes across Virginia for Commercial, Medicaid, and Medicare products. Key changes include: new prior authorization requirements for common orthopedic procedures (knee/hip arthroplasty, ankle revision), home health nursing services with benefit restrictions, new non-covered services (personal care, habilitation waivers, certain vaccines), and specific oncology lab work requiring OncoHealth contact. Billing teams must immediately update systems to enforce these requirements to avoid claim denials.
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What to do
by Sep 15, 2026 · 9 steps
01Billing team must perform the following in priority order.
02Update billing software to REQUIRE prior authorization for 16 orthopedic procedure codes (27138, 27437, 27438, 27440, 27442, 27446, 27447, 27486, 23470, 19340, L1320, 22860, 27703, A9506, S2260, S2267) for Commercial plans.
03Configure system to flag code 86152 and require routing to OncoHealth for prior auth approval on all plan types.
04Set codes T1000, G0299, G0300 to show benefit restrictions/limits in patient eligibility.
05BLOCK billing for 25 codes (T1018-T1022, T1027, T1040, T1041, T2012-T2022, H2040, G2212, 90738, 90758, 90589, 90593, 90625) - mark as NOT COVERED for Commercial plans.
06Update encounter forms and templates to alert providers of prior auth requirements for orthopedic, breast, and disc procedures.
07Train front desk to verify benefits before scheduling surgeries.
08Configure separate rules for Medicaid (codes 22860, 27703, S9365-S9367 require prior auth only).
09Failure to implement prior auth will result in automatic claim denials for orthopedic procedures.
If missed: Failure to block non-covered codes will result in patient financial liability and claim denials.
Codes mentioned
5866058673G0299G0300T100086152A9506S2260S226719340234702713827437274382744027442274462744727486L13202286027703S9365S9366S9367T1018T1019T1020T1022T1027T1040T1041T2012T2013T2014T2015T2016T2017T2018T2019T2020T2021T2022H2040G22129073890758905899059390625
Original notice
Medical and Clinical Policy Updates - Effective October 1, 2026
shc-p-001.sitecorecontenthub.cloud · Always check the source before changing claims.
Related changes
See all Sentara Health Plans changes →Authorization Updates - Effective January 1, 2027HighEffective Jan 1, 2027 · Prior AuthorizationSummer 2025 Authorization UpdatesMediumEffective Jul 1, 2025 · Prior AuthorizationAuthorization Updates - Effective June 1, 2025MediumEffective Jun 1, 2025 · Prior AuthorizationAuthorization Updates - Effective August 1, 2025MediumEffective Aug 1, 2025 · Prior AuthorizationBrowse every Sentara Health Plans change in the policy list
Related policy hubs
Sentara Health Plans policiesVA policy changesOrthopedicsGeneral SurgeryPlastic SurgeryOncologyPalliative CareOccupational TherapyPediatricsAllergy & ImmunologyCode 58660Code 58673Code G0299Code G0300Code T1000Code 86152Code A9506Code S2260Code S2267Code 19340Code 23470Code 27138Code 27437Code 27438Code 27440Code 27442Code 27446Code 27447Code 27486Code L1320Code 22860Code 27703Code S9365Code S9366Code S9367Code T1018Code T1019Code T1020Code T1022Code T1027Code T1040Code T1041Code T2012Code T2013Code T2014Code T2015Code T2016Code T2017Code T2018Code T2019Code T2020Code T2021Code T2022Code H2040Code G2212Code 90738Code 90758Code 90589Code 90593Code 90625