Filing Requirements - Rendering and/or Billing Provider
- The preferred method for claim submission to Sentara Health Plans is electronic claim submission. Claims can be submitted through a clearinghouse, Availity, Veradigm (AllScripts/PayerPath), or Change Healthcare or can be submitted directly by a Provider or vendor.
- All claims must be submitted within the guidelines of the product or they will be denied as a late claim submission.
- Claims submitted must be for Participating Providers within the practice.
- Submit paper claims on the standard CMS 1500 form for professional Providers or UB-04 form for Facilities. All claims must be “Clean Claims”
- In order 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 in order to be processed.
(Added 1/23/24)
Appointment Access Standards
Medicaid
| Service | Sentara Health Plans Medicaid Standard |
| ServiceEmergency appointments, including Crisis Services | Sentara Health Plans Medicaid Standard Emergency appointments and services, including crisis services, must be made available immediately upon the Member’s request. Follow up to crisis services must be made within 24 hours of Sentara Health Plans being notified of the crisis services utilization. |
| ServiceUrgent appointments | Sentara Health Plans Medicaid Standard Within 24 hours of the Member’s request. |
| ServiceRoutine Primary Care | Sentara Health Plans Medicaid Standard Routine, primary care service appointments must be made within 30 calendar days of the member’s request. Standard does not apply to appointments for routine physical examinations, for regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every 30 days, or for routine specialty services like dermatology, allergy care, etc.) |
| ServiceMaternity Care – First Trimester | Sentara Health Plans Medicaid Standard Within 7 calendar days of request |
| ServiceMaternity Care – Second Trimester | Sentara Health Plans Medicaid Standard Within 7 calendar days of request |
| ServiceMaternity Care – Third Trimester | Sentara Health Plans Medicaid Standard Within 3 business days of requests |
| ServiceMaternity Care – High Risk Pregnancy | Sentara Health Plans Medicaid Standard Within 3 business days of high-risk identification to Sentara Health Plans or a maternity provider, or immediately if an emergency exits |
| ServicePostpartum | Sentara Health Plans Medicaid Standard Within 60 days of delivery |
| ServiceMental Health Services | Sentara Health Plans Medicaid Standard As expeditiously as the member’s condition requires and within no more than 5 business days from Sentara Health Plans' determination that coverage criteria is met |
| ServiceLTSS | Sentara Health Plans Medicaid Standard As expeditiously as the member’s condition requires and within no more than 5 business days from Sentara Health Plans' determination that coverage criteria is met |
Commercial Plans - New
| Service | Sentara Health Plans Commercial Standard |
| ServiceEmergency appointments, including Crisis Services | Sentara Health Plans Commercial Standard Emergency appointments and services, including crisis services, must be made available immediately upon the member’s request |
| ServiceUrgent appointments | Sentara Health Plans Commercial Standard Within 24 hours of the member’s request |
| ServiceRoutine Primary Care | Sentara Health Plans Commercial Standard Routine, primary care service appointments must be made within 30 calendar days of the member’s request. Standard does not apply to appointments for routine physical examinations, for regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every 30 days, or for routine specialty services like dermatology, allergy care, etc. |
| ServicePreventive Care | Sentara Health Plans Commercial Standard Within 60 days of calendar request |
| ServiceAfter-hours Care | Sentara Health Plans Commercial Standard As a condition of participation, providers must provide covered services to members on a 24 hour per day, 7 day per week basis. |
| ServiceMaternity Care – First Trimester | Sentara Health Plans Commercial Standard Within 7 calendar days of request |
| ServiceMaternity Care – Second Trimester | Sentara Health Plans Commercial Standard Within 7 calendar days of request |
| ServiceMaternity Care – Third Trimester | Sentara Health Plans Commercial Standard Within 3 business days of requests |
| ServiceMaternity Care – High Risk Pregnancy | Sentara Health Plans Commercial Standard Within 3 business days of high-risk identification, or immediately if an emergency exists |
| ServicePostpartum | Sentara Health Plans Commercial Standard Within 60 days of delivery |
| ServiceMental Health Services | Sentara Health Plans Commercial Standard Appointment availability must be no more restrictive than for medical conditions. |
| ServiceLTSS | Sentara Health Plans Commercial Standard As expeditiously as the member’s condition requires and within no more than 5 business days from Sentara Health Plans' determination that coverage criteria are met. |
Medicare - New
| Service | Sentara Health Plans Medicare Standards |
| Service Urgently needed services or emergency | Sentara Health Plans Medicare Standards Immediately |
| Service Services that are not emergency or urgently needed, but the member requires medical attention | Sentara Health Plans Medicare Standards Within 7 business days |
| Service Routine and preventive care | Sentara Health Plans Medicare Standards Within 30 business days |
Contacts
- Provider Customer Service (Provider and member customer service numbers remain consolidated): 1-800-229-8822
- Transportation: (877) 892-3986
- Pharmacist Help Desk: (844) 604-9165
- Care Coordination: (866) 546-7924
- Network Educator: (product and service updates, escalations) contactmyrep@sentara.com
Corporate Address
(See Conducting Business Beginning July 1 for that information.) update w/corrected section name
U.S. Mail
Sentara Health Plan, Inc.
PO Box 66189
Virginia Beach, VA 23466
Overnight Mail
Sentara Health Plans, Inc.
1300 Sentara Park
Virginia Beach, VA 23464
Credentialing
Existing providers do not need to be credentialed again because of the merger. New providers seeking to join our network will initiate the process by submitting a Request for Participation form located on our website.
Email Addresses
All email addresses end “@sentara.com”
Kaiser Permanente
Kaiser Permanente member information will not be available on the Availity, Sentara Health Plans or Group Number VP secure portals. Attempts to search these members will produce a message letting the user know the member is part of the collaboration between Sentara Health Plan and Kaiser Permanente.
New Health Plan Names
| Medicare/D-SNP/C-SNP | |
| Medicare/D-SNP/C-SNPOriginal | undefinedNew |
| Medicare/D-SNP/C-SNP
Optima Medicare Value (HMO) | undefinedSentara Medicare Value (HMO) |
| Medicare/D-SNP/C-SNP Optima Medicare Prime (HMO) | undefinedSentara Medicare Prime (HMO) |
| Medicare/D-SNP/C-SNP Optima Medicare Savings (HMO) | undefinedSentara Medicare Savings (HMO) |
| Medicare/D-SNP/C-SNP Optima Medicare Salute (HMO) | undefinedSentara Medicare Salute (HMO) |
| Medicare/D-SNP/C-SNP Optima Medicare Engage – Diabetes and Heart (HMO C-SNP) | undefinedSentara Medicare Engage - Diabetes and Heart (HMO C-SNP) |
| Medicare/D-SNP/C-SNP Optima Community Complete (HMO D-SNP) | undefinedSentara Community Complete (HMO D-SNP) |
| Medicare/D-SNP/C-SNP N/A | undefinedSentara Community Complete Select (HMO D-SNP) – New Plan |
| Medicare/D-SNP/C-SNP Medicaid | |
| Medicare/D-SNP/C-SNP Optima Community Care | undefinedSentara Community Plan |
| Medicare/D-SNP/C-SNPCommercial | |
| Medicare/D-SNP/C-SNP Optima Vantage | undefinedSentara Vantage (HMO) |
| Medicare/D-SNP/C-SNP Optima POS | undefinedSentara POS |
| Medicare/D-SNP/C-SNP Optima Plus (PPO) | undefinedSentara Plus (PPO) |
| Medicare/D-SNP/C-SNP Optima Health Individual & Family Plans | undefinedSentara Individual & Family Health Plans |
Joining the Network:
New groups joining the network will join under Sentara Health Plans and begin by submitting a Request for Participation located on the website.
If you are interested in joining the LTSS network, please contact Centipede for additional information.
To Join Our LTSS Network
CENTIPEDE Health Network
Phone: (855) 359-5391
Fax: (866) 421-4135
Email: joincentipede@heops.com
CENTIPEDE Credentialing
CENTIPEDE Health
P.O. Box 291707 Nashville, TN 37229
Facility and Ancillary Providers: Contact Network Management at (877) 865-9075 to inquire about the contracting process.
To add a new provider to a practice, please submit a Provider Update Form. Please review the provider credentialing requirements prior to completing your submission.
Medicare/DSNP
Effective December 31, 2023, the CMS contracted plan Virginia Premier Advantage Elite (HMO D-SNP) will be sunset. All members in the Virginia Premier Advantage Elite plan will be auto-enrolled into the Sentara Community Complete Plan (HMO D-SNP), formerly known as Optima Community Complete. This means:
- All terms pertaining to Virginia Premier are no longer part of the Provider Agreement.
- The amended and restated Provider Agreement applies to all Members of Sentara Health Plan, regardless of their historical membership with Virginia Premier.
- Former Virginia Premier DSNP members will continue to be served under the program now known as Sentara Community Complete Select (HMO D-SNP).
- Impacted members will receive new membership cards before January 2024. Members will also get a new Member ID.
Remaining Informed
You will continue receiving the providerNEWs newsletter via email delivery. Current, and past editions of providerNEWs are available online for a limited time.
Verifying Eligibility with DMAS
Effective January 1, 2024, when determining eligibility via the DMAS provider portal, Sentara Health Plan members will be identified under Sentara Community Plan.
For dates of service before January 1, 2024, members will be identified under Optima Health or Optima (formerly Virginia Premier).
(Added 1/23/24)
When verifying eligibility for dates of service prior to January 1, 2024, please select based on the Provider IDs listed below:
- VPHP MLTSS Provider ID: 0247726240
- VPHP MED 4 Provider ID: 0562425717
- OHP OFC Provider ID: 0562427754
- OHP OHCC Provider ID: 0247719971
These provider IDs are located immediately next to the Plan Name when viewing in the DMAS portal. For dates of service after January 1, 2024, please select Sentara Community Plan.
Member Identification Cards
Important Notes:
- Member ID numbers will change.
- Optima Health Group Number VP member ID cards have been discontinued.
Medicaid
Medicare
Commercial
Medicare/DSNP
Effective December 31, 2023, the CMS contracted plan Virginia Premier Advantage Elite (HMO D-SNP) will be sunset. All members in the Virginia Premier Advantage Elite plan will be auto-enrolled into the Sentara Community Complete Plan (HMO D-SNP). The Sentara Community Complete Plan is the rebranded Optima Community Complete Plan. This means:
- All terms pertaining to Virginia Premier are no longer part of the Provider Agreement.
- The amended and restated Provider Agreement applies to all Members of Sentara Health Plan, regardless of their historical membership with Virginia Premier.
- Former Virginia Premier DSNP members will continue to be served under the program now known as Sentara Community Complete Select (HMO D-SNP).
- Impacted members will receive new membership cards before January 2024. Members will also get a new Member ID.