Prior Authorization Forms and Policies

Pre-authorization reconsideration request? Please submit the Reconsideration of a Denied Pre-Authorization form.

Advanced Imaging

PDF , 90 KB Last Updated : 05/29/2024

Behavioral Health

PDF , 242 KB Last Updated : 05/29/2024

PDF , 96 KB Last Updated : 05/29/2024

PDF , 135 KB Last Updated : 05/29/2024

PDF , 109 KB Last Updated : 07/19/2024

PDF , 169 KB Last Updated : 05/29/2024

PDF , 270 KB Last Updated : 05/29/2024

Durable Medical Equipment

PDF , 106 KB Last Updated : 05/29/2024

Home Health

PDF , 105 KB Last Updated : 05/29/2024

PDF , 100 KB Last Updated : 05/29/2024

PDF , 103 KB Last Updated : 05/29/2024

Inpatient and Outpatient Observation

PDF , 121 KB Last Updated : 05/29/2024

PDF , 107 KB Last Updated : 05/29/2024

Radiology and Oncology

PDF , 131 KB Last Updated : 05/29/2024

PDF , 246 KB Last Updated : 05/29/2024

Therapy Authorization Worksheet

PDF , 120 KB Last Updated : 05/29/2024

Transitional Care Request

PDF , 171 KB Last Updated : 05/29/2024

Urgent Request

PDF , 133 KB Last Updated : 05/29/2024

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Sentara Health Plans is the trade name for Sentara Health Plans, Sentara Health Insurance Company, Sentara Health Administration, Inc., and Sentara Behavioral Health Services, Inc. Health Maintenance Organization (HMO) products, and Point-of-Service (POS) products are issued and underwritten by Sentara Health Plans. Preferred Provider Organization (PPO) products are issued and underwritten by Sentara Health Insurance Company. Sentara Health Administration, Inc. provides administrative services to group and individual health plans but does not underwrite benefits. All plans have benefit exclusions and limitations and terms under which the policy may be continued in force or discontinued. Medicare products are administered under an agreement with Sentara Health Plans and the Centers for Medicare and Medicaid Services (CMS). Medicaid and FAMIS products are administered under an agreement with Sentara Health Plans and the Virginia Department of Medical Assistance Services (DMAS).