Delegation Update Form
Submission of this Delegation Update Form will initiate a request to review your delegated roster and process any new providers to their practice or update their information.
Note: Tax ID, Legal Business Name, product/reimbursement change requests or other changes affecting your Provider Agreement (contract) need to be submitted directly to your Sentara Health Plans Contract Manager. Please contact the Network Contracting team at 877-865-9075 for these requests.
Keeping Sentara Health Plans informed of provider updates is an important step to ensuring accurate claims payment and member satisfaction. Thank you for your continued partnership!
* All required fields are denoted with an asterisk.
This form is only for delegated providers. Please click here to complete and submit your request through the "Provider Update Form" for non-delegated providers.
Monthly Updates
Submission of this form will initiate a request to review your delegated roster and process any new provider adds, changes, and/or terminations.
Annual Reconciliations
Submission of this request is used for annual reconciliations requested by the delegate.
Please fill out the form below and attach your delegated roster using the format of the delegated roster template.
New DMAS/PRSS Enrollment
The “New DMAS/PRSS Enrollment” selection is ONLY for existing Sentara Health Plans providers to notify the health plan that the provider has registered with DMAS provider portal (PRSS) and to request participation with Sentara Community Plan (Medicaid). Your DMAS enrollment effective date is required to be submitted with this request.
Other
Use this form if the action required is not listed under "Change Requested" options.
Please fill out the form below and attach your delegated roster using the format of the delegated roster template.
