Vendor Partnerships | Sentara Health Plans

AccordantCare

The AccordantCare™ Program is designed to help members find the answers and support they need to manage their health care needs and maximize their overall health status. This specialized education and support program is offered to members with the following conditions:

Amyotrophic Lateral Sclerosis (ALS) • CIDP (Chronic Inflammatory Demyelinating Polyradiculoneuropathy) • Crohn’s Disease • Cystic Fibrosis • Dermatomyositis • Epilepsy (Seizures) • Gaucher Disease • Hemophilia • Hereditary Angioedema • Human Immunodeficiency Virus (HIV) • Multiple Sclerosis • Myasthenia Gravis • Parkinson’s disease • Polymyositis • Rheumatoid Arthritis • Scleroderma • Sickle Cell Disease • Systemic Lupus Erythematosus (SLE or Lupus) • Ulcerative Colitis

Members are identified via claims data analysis and individual case management referrals. Once identified, eligible members will receive introductory mailings and calls to enroll in the program. AccordantCare will also notify providers of program enrollment and ongoing collaboration on member’s plan of care.

Avalon

Routine Testing Management (Laboratory)

Avalon provides Routine Testing Management (RTM) services. RTM, an automated review of high-volume, low-cost laboratory tests, provides consistent application of laboratory policies while remaining provider and member friendly.

Laboratory services reported on claims will be reviewed for adherence and consistency with Sentara Health Plans laboratory policies and guidelines. Avalon will also ensure alignment with industry standardized rules, including (but not limited to) evaluating services for being experimental and/or investigational and meeting clinical appropriateness for patient demographics. Additionally, codes reporting multiple units billed will be reviewed for appropriateness to code-specific unit allowances under Sentara Health Plan’s laboratory policies and guidelines.

Avalon’s automated policy enforcement will be applied by Sentara Health Plans to claims with laboratory services provided in office, hospital outpatient and independent laboratory locations. Laboratory services, tests and procedures provided in the emergency room, hospital observation and hospital inpatient settings are excluded from this program. Avalon’s automated policy enforcement is designed to ensure the consistent application of Sentara Health Plan’s laboratory policies and guidelines to claims with laboratory services.

Policies and guidelines

Avalon Provider Training Opportunities

Avalon provides Routine Testing Management (RTM) services. RTM, an automated review of high-volume, low-cost laboratory tests, provides consistent application of laboratory policies while remaining provider and member friendly. Avalon will be hosting training sessions early next year to introduce new providers to the program and processes. Existing users are welcome to attend as well. The meeting will be facilitated through Microsoft Teams and you may join on your computer, mobile app or room device.

CareCentrix

Home Infusion Therapy

CareCentrix manages post-acute care services for our commercial members in Virginia. Provided services are as follows:

Manage authorizations for members discharged from acute care hospitals who are admitted to skilled nursing facilities or inpatient rehabilitation facilities.
Provides nurse coaching for eligible patients after an acute care hospital discharge for a period of up to 90 days to support their path to healing, reduce unnecessary readmissions, and help members achieve self-management.

If authorizations as described above are not obtained, claims may be denied.

Home Sleep Testing (HST)

CareCentrix® manages sleep testing services to our Medicare, Medicaid, and Dual Eligible Specials Needs Plan (D-SNP) members. Here is what you need to know about the CareCentrix sleep diagnostic testing program:

All requests for sleep diagnostic testing will require prior authorization from CareCentrix. This includes the following codes: 95782, 95783, 95805, 95807, 95808, 95810, 95800, 95801, 95806, G0398, G0399, and G0400.
CareCentrix will contract, credential, and manage a network of HST providers rendering services to Sentara Health Plans members. CareCentrix contracted HST providers will submit claims to CareCentrix.
Sentara Health Plans contracts and manages the provider network for facility-based sleep tests. Facility-based sleep diagnostic providers will require authorization from CareCentrix and submit claims directly to Sentara Health Plans.All sleep diagnostic testing claims submitted without an authorization may be denied.

For full details about this program, you are encouraged to visit the CareCentrix HomeBridge provider portal. Go to the Education Center (lower right box), then click on Sentara Health Plans Sleep, to view the various resources, including a recently recorded training session. Specifically, we invite you to review the revised FAQ which has been enhanced with more details on Home Sleep Test codes, prior authorization as well as how to join the CareCentrix provider network.

Carelon

Medical Oncology

Carelon manages the Sentara Health Plans Oncology Program. This is a utilization management program that requires providers to request prior authorization for therapeutic and supportive medical oncology drugs. It is also a quality initiative that enables providers to compare planned cancer treatment regimens against evidence-based, optimal cancer treatment regimens, while simultaneously ensuring prescribed regimens are aligned with Sentara Health Plans medical policies. Learn more

Radiation Oncology

Carelon Medical Benefits Management recognizes the key role that radiation oncology practices play in the delivery of care for patients with cancer. Developed in collaboration with Sentara Health Plans, the Radiation Oncology program helps support quality care that is consistent with current medical evidence. Learn more

Evolent

NIA, our Medical Specialty Solutions program vendor, is now Evolent. Services include prior authorization of nonemergent, advanced outpatient imaging and some cardiac services.
The decision to implement this program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

Under terms of the agreement, Sentara Health Plans will oversee the Evolent program and remain responsible for claims adjudication. Evolent will manage the following services:

1. CT/CTA
2. CCTA
3. MRI/MRA
4. PET Scan
5. Myocardial Perfusion Imaging
6. MUGA Scan
7. Stress Echocardiography
8. Echocardiography
9. Cardiac Implantable Devices (defibrillator, pacemaker, resynchronization therapy)
10. Left Heart Catheterization

Please note the following:

• The ordering physician is responsible for obtaining authorization prior to rendering the above-listed services.
• Providers rendering the services listed above should verify that the necessary authorization has been obtained by visiting RadMD.com or by calling Evolent at 1-800-424-1663. Failure to do so may result in nonpayment of your claim.
• Emergency room, observation, and inpatient procedures do not require authorization.
• Authorizations for imaging and cardiac services for fully-insured plans will be managed by Evolent.
• Authorizations for imaging and cardiac services for self-insured plans will be managed by Sentara Health Plans. Self-insured plans may opt into the program in the near future and notification will be made as this occurs.

Updated 5/7/24

Modivcare – New

Modivcare, our new transportation vendor, administers non-emergency transportation benefit for Medicaid and Medicare members effective January 1, 2024. The transportation benefits will remain the same as previously provided to members. For details visit their website.

Performant - New

Performant offers audit and payment integrity services to payers of healthcare claims, according to industry standards. Services include identification and resolution of underpayments and overpayments resulting from erroneous claims submissions or payments. The company serves government and private organizations that outsource their services to agencies whose core competencies are in the examination and resolution of healthcare related assets. Performant is an experienced vendor performing SNF audits for RAC1 and RAC2, as well as many commercial plans that reimburse under PDPM.

Performant has experienced RN SNF auditors, many holding RNAC certifications, and several with advanced certifications for RAC-CTA. The audit team has deep knowledge of PDPM reimbursement. The team validates every element of the IP SNF stay to ensure that the HIPPS code billed is accurate. Medical directors are also on staff for review if needed.

Performant and Sentara Health Plans will be working together in outlining business objectives which help target and select claims for audit using Performant’s algorithms based on several key factors identifying claims with potential for error. While these audits are a required regulatory obligation for the health plan, we understand the potential challenges for the provider community and have established audit processes that will ease administration for providers, as well as a clearly defined feedback loop to support inquiries during audits.