Appeal Information
A Sentara Community Plan member or their authorized representative (including an attorney) may file an appeal for reduced, terminated, or denied requests for service or denied claims (also called an adverse action). An appeal can be initiated by phone, fax, or mail. An appeal form should be signed by the member if the appeal is sent by an authorized representative. Appeals should be sent to:
Appeals and Grievances
PO Box 62876
Virginia Beach, VA 23466
Phone: 1-844-434-2916 (TTY: 711)
Fax: 1-866-472-3920
State Fair Hearing Process
If the service remains denied after submitting an appeal to Sentara Health Plans, the member or their authorized representative may request a DMAS State Fair Hearing. To appeal to DMAS, the member should contact the DMAS Appeals Department at 804-371-8488 or send a written request within 120 calendar days of receipt of an appeal denial notice to:
Department of Medical Assistance Services
Appeals Division
600 East Broad Street
Richmond, VA 23219
External Review Process – FAMIS Members
As part of the State Fair Hearing appeal request, FAMIS members can request an external medical review from Acentra Health (formerly KEPRO). You or your representative acting on your behalf can file the external medical review request in the following ways:
Online at https://dmas.kepro.com by clicking the external appeal link.
Mail to:
Acentra/KEPRO External Review
6802 Paragon Place, Suite 440
Richmond, VA 23230
Additional information on the State Fair Hearing Appeal process is available at https://www.dmas.virginia.gov/.
Member Appeal PacketGrievance Information
Sentara Health Plans would like our members to be completely satisfied with the medical care and services they receive. Therefore, if you have a problem or complaint concerning the operation of the plan, access to services, timeliness or quality of services provided, pre-authorization decisions or assignment of primary care provider (PCP); or any other issue with your care or the health plan, a process has been developed for you to register your complaint so it can be resolved to your satisfaction. Should a problem or an incident cause you dissatisfaction, you can submit a member grievance to:
Appeals and Grievances
PO Box 62876
Virginia Beach, VA 23466
Phone: 1-844-434-2916 (TTY: 711)
Fax: 1-866-472-3920