CommercialPrior AuthMedium impact
Authorization Updates - Effective February 1, 2027
Sentara Health Plans·VA · Pain Management, Orthopedics, Emergency Medicine·Prior Authorization
Effective date
Feb 1, 2027
We identified it
Oct 22, 2026
Summary
Effective February 1, 2027, Sentara Health Plans will require prior authorization for nine specific medical codes related to injectable/therapeutic joint procedures and ambulance services for all Commercial products in Virginia. Additionally, DMAS has already restricted coverage (effective October 13, 2026) of gender-affirming procedures for Medicaid and CHIP youth, though this does not change billing requirements—only coverage eligibility.
Action Required
By February 1, 2027: Billing team must update the billing system to require prior authorization/precertification for CPT codes 0213T, 0214T, 0216T, 0217T, 0218T and HCPCS codes A0431, A0998, S9960, S9961 for all Sentara Health Plans Commercial products in Virginia. Front-office and clinical staff should be notified that these codes cannot be billed without prior authorization approval. Claims submitted without required prior authorization will be denied. Additionally, verify that the practice is currently declining coverage for gender-affirming procedures (including hormone therapy) for Medicaid/CHIP members under age 18/19 as applicable, effective October 13, 2026—confirm current applicability with Sentara and DMAS documentation, as this coverage change is already in effect.