This Provider Update Form is to be utilized by providers who have had a change to their provider/practice information (i.e. address change, panel status change, terminations, etc.), or who want to add a new provider to their practice (request provider credentialing). Please 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! If your provider/practice (Tax ID) is not currently participating, or not currently in the contracting process with Sentara Health Plans, please DO NOT submit this form. If you are interested in participating with Sentara Health Plans, please complete the "Request for Participation" form on the Join our Network page of www.sentarahealthplans.com/providers .
A new provider joining a new group/Tax ID (newly contracted or in the contracting process with Sentara Health Plans).
Submission of this form will initiate the practitioner credentialing process if the provider is not already credentialed with Sentara Health Plans.
Prior to submitting this request, please ensure to review and complete credentialing requirements available on the Update Your Information page on www.sentarahealthplans.com
A new provider joining an existing/already participating group/Tax ID.
A provider leaving one participating practice and joining another participating practice. Fields should be completed with the NEW practice information.
If the provider is not already credentialed with Sentara Health Plans, submission of this form will initiate the practitioner credentialing process.
Practitioner is staying at current practice and joining an additional participating practice. Fields should be completed with the NEW practice information.
A practitioner has a new primary service address. Fields should be completed with the NEW practice information.
Any Billing Address changes for the practitioner/group requires a W-9 attached.
Fields should be completed with the NEW billing information.
A Practitioner or Practice is adding an additional address or leaving a current additional address location.
If new address for the Practice: add additional provider name and NPI who will render services at that address in the comments section.
This form is appropriate for specific changes to an existing practice outside of address.
If you need to update an address, please use the appropriate change option specific to the address type (primary, additional, and/or billing).
We only need address information to apply the appropriate updates.
A change specific to the practitioner (not including addresses) that will apply to all practices the practitioner renders services at.
Examples: Name Change, Cultural Competency, Email, Languages.
Please fill out required fields and only those fields that need to be updated in our system.
Please update the requested panel statuses below and include any relevant comments.
A Provider is leaving their current practice and/or terminating from the Sentara Health Plans Network.
This request type is only applicable for Mental Health Counselors and Licensed Marriage and Family Therapists.
The “New Medicare Enrollment” selection is ONLY for existing credentialed Sentara Health Plans providers to notify the health plan that the provider has enrolled with CMS/Medicare and to request participation with Sentara Health Plans Medicare.
Your Medicare enrollment effective date is required to be submitted with this request. Please enter your effective date in the Comments section of this form.
The “New DMAS/PRSS Enrollment” selection is ONLY for existing credentialed Sentara Health Plans providers to notify the health plan that the provider has registered or revalidated with DMAS (PRSS) and is requesting participation (or re-instatement of participation) with Sentara Health Plans Medicaid.
Your DMAS enrollment effective date is required to be submitted with this request. Please enter your effective date in the Comments section of this form.
