MedicaidPrior AuthMedium impact
Authorization Updates Changes - July 1, 2026
Sentara Health Plans·VA · Oncology, Rheumatology·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Oct 8, 2026
Summary
This is a reminder that prior authorization has been required for Denosumab biosimilar codes Q5157 and Q5136 (oncology and osteoporosis indications) since July 1, 2026, and will continue to be required going forward. The PAL Web Tool is being updated to reflect these existing authorization requirements. Providers must submit authorization requests before rendering or billing these services to avoid claim denials.
Action Required
Already effective since 2026-07-01: Verify that the billing team has implemented and is consistently enforcing prior authorization requirements for codes Q5157 and Q5136 before claim submission for all Medicaid products in Virginia. Confirm that authorization requests are submitted prior to rendering or billing these services. Monitor the PAL Web Tool for any system updates reflecting these authorization requirements. Document current authorization workflows to ensure ongoing compliance and prevent claim denials.