CommercialPrior AuthHigh impact
Medical and Clinical Policy Updates - Effective December 1, 2026
Sentara Health Plans·Orthopedics, Neurosurgery, Pain Management +3 more·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 15, 2026
Summary
Sentara Health Plans has updated 27 medical and surgical policies effective December 1, 2026, including revisions to high-volume procedures like lumbar/cervical fusion, diabetes management, urinary incontinence treatment, and prescription digital therapeutics. Three DME policies (Needless Injections, Mechanical Stretching Devices, Home Traction Devices) have been archived and are no longer covered. Billing teams must review affected policies on the PAL and update prior authorization requirements accordingly.
Action Required
By November 24, 2026: (1) Billing team must access pal.sentarahealthplans.com and sentarahealthplans.com to review all 27 updated policies, particularly Surgical policies 116-122 (fusion/laminectomy procedures), Medical 130 (incontinence), Medical 259 (digital therapeutics), and Medical 352 (diabetes). (2) Update billing system rules and prior authorization workflows for revised policies (Surgical 119, 214; Medical 130, 259, 352). (3) Remove archived DME policies (DME 26, 31, 35) from coverage lists in billing software and encounter forms—claims for these services will be denied effective 12/1/2026. (4) Notify providers and clinical staff of policy changes via staff meeting or email. (5) Test updated prior authorization rules in billing system before December 1. Action required by: Billing team, system administrators, and practice management. Consequences: Claims submitted under archived or outdated policies will be denied; failure to implement prior auth changes will increase claim rejections.