Claims Operations and Related Information | Sentara Health Plans (2024)

Business Run Out for Optima Health and Group Number VP

Claims Processing

- Claims runout periods will extend through the timely filing duration of the provider agreement. This will apply to both Optima Group: VP (Medicaid) and Virginia Premier DSNP (Medicare) claims.
- Paper claims can be submitted through the existing channels for run out.
-We will apply internal processes to re-route claims submitted to the incorrect location.
- Providers should use 54154 payer ID.
- Change Healthcare users only must use VAPRM for claims runout for Optima Group: VP.

The Claim Adjustment/Reconsideration Form

Span Billing for Outpatient Services

Outpatient providers will be required to bill span dates crossing over 1/1/24 separately, with service dates prior to 1/1/24 billed distinctly from those following 1/1/24. Except for interim billing, inpatient/facility claims will be adjudicated based on the admit date and will not require a separate bill.

Claims Submission Starting January 1st

Beginning on January 1, all providers can use the 54154 for both runout and future business for all current participating clearinghouses with one exception, Change Healthcare submitters only, should continue to utilize VAPRM for Group Number VP claims runout activity until further notified.

Electronic Submissions
- We accept claims through any clearing house that can connect through Availity, Veradigm (Payerpath/Allscripts) or Change Healthcare.

Mail Paper Claims to:

Medical Claims: PO Box 8203, Kingston, NY 12402-8203
Behavioral Health Claims: PO Box 8204, Kingston, NY 12402-8204

Timely Filing

As a reminder Sentara Health Plans allows 365 days for initial timely filing from the service date for all claims.

For Medicaid, all PAR and non-PAR providers are given 365 days to file reconsideration claim. For non-PAR Medicare providers have 60 days from claim adjudication date to file reconsideration
and must also submit “Waiver of Liability” which states they will not balance bill patient regardless of reconsideration outcome.

More information


Reconsiderations (sometimes confused with claims corrections) is a provider written notification to dispute the processed claim payment/denial.

Submit reconsiderations through the following methods:

1. Online Using Group Number VP Portal:

- All Group Number VP claims for DOS prior to 1/1/24
- Optima Health Medicare claims for DOS 5/1/23 forward
- All Sentara Health Plan Medicaid and Medicare claims for DOS 1/1/24 forward

2. Mail

- Medicaid and Medicare are optional
- Commercial reconsiderations must still be mailed until further notice

• Medical Claims: PO Box 8203, Kingston, NY 12402-8203
• Behavioral Health Claims: PO Box 8204, Kingston, NY 12402-8204

Corrected Claims Corrections on paper can be mailed to:

Medical Claims: PO Box 8203, Kingston, NY 12402-8203
Behavioral Health Claims: PO Box 8204, Kingston, NY 12402-8204

CMS 1500: Corrected claims submitted on a paper CMS 1500 form should include the original claim number and submission code 7 in field 22 to prevent misidentification of the corrected claim as a duplicate submission. Until further notice, corrected claims submitted on a CMS 1500 form can also be submitted electronically (without attachments) through Provider Connection.

UB04 The bill type should end in 7 with original claim number showing in field 80 to prevent misidentification as a duplicate submission.

Medical Providers may submit corrected claims online through Provider Connection by selecting Medical Claims, selecting the claim in question, and choosing the Correct Claim option. You may make corrections online to CPT code, diagnosis, billed charges, quantity and/or place of service.

Prior to submitting corrected claims electronically, please contact your clearinghouse to learn their requirements.

Consistent with Health Insurance Portability and Accountability Act (HIPAA) requirements, please submit corrected claims in their entirety following these guidelines:

Make the changes in your practice management system, so the corrections print on the amended claim. Please do not make handwritten corrections on the claim.
Send the entire corrected claim (even line items that were previously paid correctly). The corrected claim will be compared to the original claim and all charges for that date of service. Any partially corrected claim will be denied.

Provider and patient information must be included on the claim.

Physician claims: Enter 7 in electronic field 12A or box 22 of the paper CMS-1500 form.

Facility claims: UB Type of Bill should be used to identify the type of bill submitted as follows:

XX5 Late charges only
XX7 Replacement of previous bill (corrected claim)
XX8 Void/cancel previous claim

Appeals – Sentara Health Plans will continue the practice of accepting appeals submitted in writing within 365 days from the date of service for claims appeals. Clinical appeals must be submitted within 60 days of notice of denial, unless otherwise determined by their contract with the health plan. Detailed information and supporting written documentation should accompany the appeal. A decision will be rendered within 30 business days of receipt of the appeal request, with a 14-day extension if it is in the best interest of the member.

Mail to:

Sentara Health Plans Appeals and Grievances
PO Box 62876
Virginia Beach, VA 23466

Medicaid Provider Services: 800-881-2166
Medicaid Appeals and Grievances Phone: 844-434-2916
Medicaid Fax: 866-472-3920

Medicare Provider Services: 800-927-6048
Medicare Appeals and Grievances Phone: 855-813-0349
Medicare Fax: 800-289-4970

Remittance Advice

Beginning on January 1, 2024, all Sentara Health Plans Medicare and Medicaid products will be processed on a single remit and an active PaySpan Account will be required. The EFT enrollment process for commercial and self-funded products remains as follows until further notice:

1.Complete in its entirety the

EFT/ERA Authorization Agreement PDF form

2.Obtain a letter from your bank on the bank’s letterhead, including the physical bank
address, account number, the bank employee’s name, title, email, and phone number.
Letter must not be dated more than 90 days prior.
3. The form must be signed by the provider or an authorized representative of the provider.
4. Submit all the documents by email to

5. Optima Health will validate the provider’s relationship with the banking institution.
6. Tax ID information will be validated in the payment System.
7. Once the process is complete, the EFT information will be input into the payment system
and the Provider will be notified that the set-up has been completed.

Register for PaySpan
To start the PaySpan registration process, you may contact

or call 1-877-331-7154, option 1 to obtain the registration codes and assistance with navigating the website. You will receive the requisite registration code and can also request assistance with navigating the website. PaySpan is available Monday – Friday, 8 a.m. – 8 p.m.

Learn more

Negative Balances
For Optima Group VP (formerly Virginia Premier) providers, beginning on January 1, recoupments will no longer appear on your EOPs as an advance. You will begin receiving a monthly negative balance statement around the first Friday of every month for claims that are being held to offset monies owed for claims that are unable to be retracted as well as refund request letters for the claims owed back to the health plan.

Note: Providers are required to register with PaySpan if they do not have an active account. Providers with active accounts that attempt to register again will receive the message "There is no registration code available." If this occurs, the provider must contact PaySpan directly at


Claims Operations and Related Information  | Sentara Health Plans (2024)


What clearinghouse does Sentara use? ›

Electronic Submissions - We accept claims through any clearing house that can connect through Availity, Veradigm (Payerpath/Allscripts) or Change Healthcare. As a reminder Sentara Health Plans allows 365 days for initial timely filing from the service date for all claims.

What are Sentara Health Plans? ›

Sentara Health Plans is a regional health plan that partners with PHCS/MultiPlan to provide national coverage for our members with PPO (Plus), POS, or POSA plans. Please file your claim as you normally would and Sentara Health Plans will work with PHCS/MultiPlan to adjudicate and pay your claim.

What is the timely filing limit for Optima? ›

Optima Health has a timely filing limit for claim submissions. Claims must be received within 365 days from the date of service.

Is Optima owned by Sentara? ›

Optima Health has changed our name to Sentara Health Plans to better reflect our enhanced focus on promoting the overall health and well-being of our consumers.

What clearinghouse does Unitedhealthcare use? ›

Optum Intelligent Electronic Data Interchange (iEDI) - UnitedHealth Group.

What clearinghouse does availity use? ›

The Availity Network: Your Connection to Payers Nationwide

No matter how large or small your organization, our EDI Clearinghouse solution gives you access to our nationwide network, along with flexible contracts and competitive pricing.

Can you bill a patient if a claim is denied for timely filing? ›

Even if the physician fails to submit a claim on time, California law provides a “good cause” exception that requires payors to accept and adjudicate a claim if the physician demonstrates, upon appeal, “good cause” for the delay.

Is Optima Health and Virginia Premier merger? ›

Effective July 1, Virginia Premier will rebrand as Optima Health. The health plans are transitioning to full integration on January 1, 2024. Optima Health Group Number VP = the health plan formerly known as Virginia Premier.

How long do I have to submit a claim to Cigna? ›

Filing a claim as soon as possible is the best way to facilitate prompt payment
If you are...Submit by...
If you are... A participating health care provider An out-of-network providerSubmit by... 90 days after the date of service 180 days after the date of service
6 days ago

What is the best health insurance in va? ›

MoneyGeek Pick for PPO: CareFirst Blue Cross Blue Shield

MoneyGeek's top pick for the best health insurance in Virginia for Silver PPO plans is CareFirst Blue Cross Blue Shield. It offers two Silver PPO plans. These plans have an average monthly plan rate of $917 and an average maximum out-of-pocket cost of $7,800.

Who is sentara merging with? ›

Sentara Healthcare acquires AvMed, Inc.

Sentara Healthcare, one of the largest not-for-profit integrated health care delivery systems in the U.S. Mid-Atlantic region, has finalized the transaction with SantaFe HealthCare, Inc., for ownership of AvMed, Inc. , a not-for-profit health plan in Florida.

When did Optima change to Sentara? ›

On January 1, 2024, Sentara announced a significant development in our commitment to providing exceptional healthcare: Optima Health and Virginia Premier consolidated under a new name, Sentara Health Plans.

What EMR system does sentara use? ›

Dubbed Sentara eCare, the Epic EHR system connects the Norfolk, Va. -based health system's 12 hospitals and various clinics on the same platform. With the EHR, clinicians can access and exchange patient electronic medical records more quickly.

What is NextGen clearinghouse? ›

NextGen Clearinghouse (formerly ViaTrack) is a medical clearinghouse platform designed for medical and dental practices and small hospitals.

Is Athenahealth a clearinghouse? ›

Features and services. Address payer issues before they arise, speed up your revenue cycle, and increase staff productivity with our proven, all-payer clearinghouse. athenaEDI offers advanced analytics as well as a wide range of offerings that help reduce your cost to collect.

Is CareCloud a clearinghouse? ›

If you want to boost your practice revenue, look only as far as CareCloud. It provides professional medical billing services, including a clearinghouse, to help providers avoid late payments and claim rejections.


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