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Clinical Policy Updates - Effective January 1, 2026
Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Nov 3, 2026
Summary
Effective January 1, 2027, Sentara Health Plans will require prior authorization and/or step therapy precertification for 17 injectable oncology and hematology codes (filgrastim, sargramostim, bevacizumab, pegfilgrastim, rituximab, and trastuzumab products and biosimilars) for Medicare Advantage members in Virginia. The billing team must obtain prior authorization before claims are submitted to avoid denial.
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What to do
by Jan 1, 2027 · 4 steps
01Billing team: Update charge entry and claim edits to flag all 21 affected HCPCS codes (J1442, J2820, Q5110, Q5125, Q5148, J9035, Q5126, Q5160, J1449, J2506, Q5120, Q5122, Q5127, Q5130, J9311, J9312, J9355, J9356, Q5113, Q5117, Q5146) for Sentara Health Plans Medicare Advantage members in Virginia.
02Providers and front desk staff: Do not schedule or bill these injectable codes without obtaining prior authorization and step therapy precertification from Sentara first.
03Billing team: Retain documentation of prior authorization approvals and include authorization numbers on claims.
04Billing team: Watch for claims denial if prior authorization is not obtained; resubmit with proof of authorization or appeal denials with the authorization documentation.
Codes mentioned
J1442J2820Q5110Q5125Q5148J9035Q5126Q5160J1449J2506Q5120Q5122Q5127Q5130J9311J9312J9355J9356Q5113Q5117Q5146
Original notice
Clinical Policy Updates - Effective January 1, 2026
shc-p-001.sitecorecontenthub.cloud · Always check the source before changing claims.