CommercialCoverageHigh impact
Medical and Clinical Policy Updates - Effective November 1, 2026
Sentara Health Plans·Urology, Cardiothoracic Surgery, Physical Therapy +14 more·Medical Policy
Effective date
Nov 1, 2026
We identified it
Aug 25, 2026
Summary
Sentara Health Plans has updated 45+ medical policies effective November 1, 2026, including revisions to urinary incontinence treatments, cardiac implants, electrical stimulation, and extensive diagnostic testing policies (genetic, pathogen, cancer screening, biomarker testing). Multiple policies were archived (coccygectomy, gait analysis, oral incontinence treatments, injectable fillers). This is a comprehensive refresh affecting prior authorization requirements, coverage criteria, and billing across multiple service lines.
Action Required
By October 15, 2026: (1) Billing team must access the complete revised policies at sentarahealthplans.com and pal.sentarahealthplans.com to identify specific billing code changes, prior auth requirements, and coverage criteria for all 45+ updated policies. (2) Update billing software system to reflect new prior authorization requirements for revised policies (Medical 130, Surgical 106, Medical 349, Medical 350, Surgical 131, Medical 344, DME 04, DME 41, DME 42, and all Avalon G and M codes listed). (3) Remove archived policies from internal coverage guidelines and billing workflows (Surgical 114, Medical 345, Medical 153, Surgical 220). (4) Verify which policies apply to your specific service lines (Commercial, Medicaid, Medicare) and update encounter forms accordingly. (5) Distribute updated policy summaries to providers by November 1, 2026 effective date. Claims submitted without compliance to new requirements may be denied or require rework.