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Medical and Clinical Policy Updates - Effective November 1, 2026
Act
by Nov 1, 2026
Effective date
Not stated in the notice
Identified
Oct 29, 2026
Summary
Sentara Health Plans has released a Fall 2026 provider newsletter containing multiple medical policy updates across three effective dates: November 1, 2026, December 1, 2026, and January 1, 2027. These updates include policy revisions, archival of outdated policies, and new reviews affecting medical, surgical, DME, behavioral health, and pharmacy coverage across Commercial, Medicaid, and Medicare plans. The billing team must identify which policies affect the practice's specific service lines and implement corresponding prior authorization and documentation changes by each stated effective date.
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What to do
by Nov 1, 2026 · 7 steps
01Billing and clinical teams should review all policies listed with status 'Revised' or 'Archived' in the July Policies section (Medical 130, Surgical 106, Medical 345, Medical 153, Surgical 220, Medical 349, and Avalon policies G2006, G2035, G2054, G2113, G2149, G2155, G2174, G2181, M2017, M2026, M2030, M2032, M2038, M2072, M2075, M2087, M2091, M2097, M2175, M2178, M2179, and R2162) and determine applicability to your service lines.
02Update prior authorization workflows, billing software, and clinical documentation templates to reflect revised coverage criteria.
03By December 1, 2026: Implement changes for August Policies (including Medical 130, Medical 259, Medical 352, Surgical 119, Surgical 214, and 20+ surgical and medical policies affecting Commercial, Medicaid, and/or Medicare).
04Verify that archived policies (DME 26, DME 31, DME 35) are removed from authorization requirements.
05By January 1, 2027: Implement Surgical 60 (Ophthalmic Procedures) revisions for Commercial and Medicaid plans.
06Access the full policy text at sentarahealthplans.com and the Prior Authorization List at pal.sentarahealthplans.com to confirm specific coverage and authorization requirements by service line and plan type.
07Document all changes in your compliance and billing procedures.
Original notice
Medical and Clinical Policy Updates - Effective November 1, 2026
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