Conducting Business

Availity Portal - New

Beginning January 1, 2024, we are partnering with Availity to improve payer-provider collaboration and reduce administrative burdens as well as eliminate manual processes and provide more self-service features.

The good news is 91% of our providers are already working in the Availity Essentials portal and can use the same user ID and password to log in to your Essentials account, allowing for a smoother transition. For a refresher, you may view the Reference Guide for Admins and Reference Guide for Users at any time.

We strongly encourage providers who are not already using Availity Essentials platform to register today.  You can start by visiting Availity.com, click on Get Started where you can Create an Account and find an abundance of resources, including a recorded webinar that you can watch 24/7 at your convenience. Once you have your Availity Essentials account, navigate to the “Help and Training” button in the upper right-hand corner of your home screen, then select “Get Trained” for additional training options.

Updated 12/13/23: We had previously communicated we would be going live with Eligibility and Benefits, Remittance Viewer, and Claim Status features on Availity beginning 1/1/24; however, to ensure we provide the best user experience we will implement these features later in 2024. (See Implementation Matrix below).

Features Available January 1 - Updated 12/13/23 
Claims Submission: Submit claims electronically by completing a claim data entry form for both professional and institutional claims.
Payer Space:

• Connect to the Optima Health and Group Number VP legacy portals to conduct transactions not yet available in Availity, such as authorizations, claims corrections and reconsiderations. 
• Access helpful resources, such as provider manuals, demographic update forms, value based and quality program information, Prior Authorization Tool (PAL) and more. 
• Access our newsletters and other important updates and announcements. 

Transitioning to Availity Essentials

The change to Availity Essentials will occur in three (3) phases. To prevent a loss of critical functions or in some cases to immediately provide access to new conveniences, the original portals for both plans will remain available. New log in credentials will not be required if you have an active Availity Essentials account. Please note that the pathway to the eventual sunsetting of the Group Numbe VP portal necessitates disabling the auto authorization feature that has been available for select services, effective January 1, 2024.

All providers may register for the Optima Heath Group Number VP portal to submit reconsiderations and appeals for Medicare and Medicaid lines of business electronically.  This is optional and available for your convenience until the feature becomes available in Availity. 

Please review the matrix below (updated 3/1/24) to learn which features will be available in each portal as well as the projected release of new features in Availity.

Effective March 1, remittances will be viewable through Availity Essentials beginning with January 1 dates of service.

View Claim Status and Submit Reconsiderations and Appeals Online –
• Register for Optima Health portal to perform all existing features, if more convenient.
Due to the high volume of requests for access to Provider Connection, response may be delayed.  To avoid further delays or denied requests, you must supply a unique email address for each user.  Also, each email address must be linked to an individual and not an organization.
• Register for Optima Health Group Number VP Portal to view claim status and to submit reconsiderations for Medicare and Medicaid claims until the feature is implemented in Availity

Reconsiderations – Legacy Virginia Premier Portal Registration Tip

1. After receiving a success message when registering for the legacy Virginia Premier Portal you will have seven (7) days to complete enrollment in 2FA. 
2. If you exceed 7 days, you will no longer be able to enroll in 2FA. 
3. Each email address can only have one direct login account, so they cannot create a new duplicate account with the same email address.  
4. The user must start their 2FA enrollment period over again, which will grant another 7 days.

 

EDI 

Effective January 1, 2024, to process a claim, we require a valid W-9 for the provider tax identification number (TIN) on file with Sentara Health Plans.  Claims submitted without a W-9 may be rejected by a clearing house or Sentara Health Plans, or administratively denied.  We may require that any claim submitted without a valid W-9 on file be resubmitted to be processed.
(Updated 1/23/24)

Member Identification Cards Samples

Important Notes:

• Effective 01/01/2024, Sentara Health Plan members will receive new member ID numbers for the former Optima Health Medicaid plans, Member ID numbers will remain the same for all other former plans; Virginia Premier DSNP plan, Optima Medicare plans, Optima Medicaid Group VP (Virginia Premier) plan & Optima Commercial plans.
• Group Number VP member ID cards have been discontinued.
• This is not an exhaustive list of Sentara Health Plans member identification cards

Medicaid

(Updated 1/23/2024)

Medicare

Commercial

Kaiser Permanente

Famis

Medicaid

Optima Health Group Number VP Portal Access

While we strongly encourage immediate use of the Availity portal, Provider Connection and the Optima Health Group Number VP portal will remain accessible until further notice.

Claims reconsiderations may be submitted for new and existing claims through the Group Number VP claims portal.  Access to the portal will also facilitate business run out.  We anticipate the claims reconsideration feature will become available through Availity during the third quarter of 2024.

You will be able to access the portal through the Availity payer space to:

• View claim status. 
• Submit reconsiderations and appeals.

 

Submitting Provider Updates

This process was integrated in July 2023.  Please notify us as soon as possible of any changes related to your practice’s operations or to the provider roster using our convenient electronic submission process. 

Our provider update process is intended for providers who are currently contracted with Sentara Health Plan or are in the contracting process. If your practice/organization (tax ID) is out of network, and interested in joining our network, please complete the Request for Participation form on the Join our Network page.

Adding a new provider to your practice? Please review the provider credentialing requirements prior to submitting your Provider Update Form.

If you are a participating provider, and need additional assistance related to provider data updates, please email: pustatus@sentara.com