---
title: Sentara Community Plan ABA coverage (Cardinal Care MCO).
url: "https://carelu.com/payers/sentara-community-plan"
markdown_url: "https://carelu.com/payers/sentara-community-plan.md"
state: VA (Virginia)
payer: Sentara Community Plan (VA)
kind: Medicaid managed care plan (MCO)
parent_program: Virginia Medicaid (DMAS)
description: "How Sentara Community Plan (formerly Optima/Virginia Premier) administers Virginia Medicaid ABA — the new DMAS units-per-code preservice form, fax and portal channels, the BCBA change-request workflow, and the PAL lookup tool."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Sentara Community Plan ABA coverage (Cardinal Care MCO).

_Payer Guide · Sentara Community Plan · Last updated September 2026 · 6 primary sources_

> First to post the new DMAS units-per-code form; dedicated BCBA-change workflow, PAL lookup tool.

Sentara Community Plan — the Cardinal Care MCO formed from Optima Family Care and Virginia Premier — runs ABA as a pure pass-through of DMAS forms and criteria, and it was the first plan to post the new DMAS units-per-code preservice form (for dates of service September 1, 2025 onward, ahead of the statewide October 15 mandate). Its plan-specific value is workflow tooling: dedicated fax lines, a PA lookup tool, and a standing BCBA change-request form that most plans lack.

This plan administers the **Virginia Medicaid (DMAS)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Virginia Medicaid (DMAS) guide](https://carelu.com/payers/virginia-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required — DMAS rule; Sentara's ABA forms cover treatment codes only [4][2]
- **Prior auth for treatment**: Required — new DMAS preservice form (posted for DOS 9/1/2025+); fax (844) 895-3231 [2][6]
- **Autism diagnosis required?**: NO — not autism-restricted, and not category-restricted either. DMAS Appendix D admits a youth under 21 who meets criteria for a primary ICD diagnosis correlating to a DSM diagnosis, OR who has a provisional psychiatric diagnosis developed by an LMHP when no definitive diagnosis has been made, plus at least two functional-impairment criteria. The ABA criteria name no diagnostic category list and never mention autism [4]

## At a glance

- **Plan type:** Cardinal Care MCO (ex-Optima Family Care / Virginia Premier)
- **Clinical rules:** DMAS criteria + standardized forms, verbatim
- **Assessment auth:** None — DMAS assessment codes are auth-free
- **Submission:** Provider portal or BH fax (844) 895-3231 / (757) 963-9620
- **Supervisor changes:** Dedicated BCBA Change Request Form (upd. 3/2026)
- **PA lookup:** pal.sentarahealthplans.com

## How Sentara runs ABA authorization

Treatment requests use the DMAS preservice service-authorization form — the units-per-code version Sentara posted for dates of service September 1, 2025 and after — plus the matching continued-stay form. The form itself embeds the DMAS rules: units requested per CPT code, and the 20-hours/80-units threshold that triggers the individualized activity schedule. Its worked example models 2 hours/day × 5 days × 24 weeks — roughly 6-month authorization spans as the norm. Non-urgent behavioral-health authorizations fax to (844) 895-3231 or (757) 963-9620 (effective August 2025); behavioral-health provider services runs at (757) 552-7174 / (800) 648-8420, and the PAL lookup tool at pal.sentarahealthplans.com answers code-level questions. [1][2][6]

Two housekeeping notes: directory entries under "Optima" are stale — it's all Sentara Community Plan under Cardinal Care now — and supervisor changes have their own administrative workflow via the BCBA Change Request Form (updated March 2026), so a supervising-BCBA transition is paperwork, not a new authorization battle. [1][2][6]

## Intake gates

The questions that decide whether a family can start with Sentara Community Plan (VA), and what they have to bring.

- **Age limit**: Follows the Virginia Medicaid (DMAS) rule: under 21 — Appendix D's ABA admission criteria state it as the first requirement, and the benefit rides EPSDT, so there is no hard hour cap beneath it. [4][2]
- **Diagnosis recency**: Follows the Virginia Medicaid (DMAS) rule: no recency window on the diagnosis. Appendix D admits on a current primary ICD diagnosis correlating to a DSM diagnosis, or on a provisional psychiatric diagnosis developed by an LMHP where no definitive diagnosis has been made — and DMAS states there is no timeframe for the use of a provisional psychiatric diagnosis, expecting the LBA to follow up with the youth's physician or other LMHPs as more information is gathered. What must stay current is the assessment: it is reviewed and updated at least annually by the LBA, LABA or LMHP, and continued-stay criteria test symptoms within the past 30 days. [4][5][2]
- **Who may diagnose**: Follows the Virginia Medicaid (DMAS) rule: two different questions, and Appendix D answers both. The diagnosis: the youth must currently meet criteria for a primary ICD diagnosis that correlates to a DSM diagnosis, or have a provisional psychiatric diagnosis as developed by an LMHP — Appendix D does not restrict the benefit to autism or name a specialty list of diagnosing clinicians. The ABA assessment: it must be completed by an LBA, LABA or LMHP acting within scope (an LMHP-R, LMHP-RP or LMHP-S with completed education and training in ABA may complete it under the supervising LMHP), conducted in person with the youth and the family or caregivers, and an assessment completed by an LABA may be used only for ABA, not as a Comprehensive Needs Assessment for other services. [4][5][2]
- **Diagnostic tools required**: Follows the Virginia Medicaid (DMAS) rule: the initial assessment must include a functional assessment using validated tools, completed by the LBA, LABA or LMHP within scope, and documentation must describe any assessment tools used. DMAS publishes no approved list — the QHP may use clinical judgement to choose the best assessments for the youth — so what is audited is that a validated instrument was used and named, not which one. [4][5][2]
- **Referral required?**: Follows the Virginia Medicaid (DMAS) rule: no physician order. DMAS retired the requirement for an order or letter recommending services signed by a physician, nurse practitioner or physician assistant — what replaced it is a notification duty: the QHP must notify the youth's primary care physician that the child is receiving ABA, providers must communicate the results of the assessment and treatment planning to the PCP, and care coordination with the PCP must be documented in the youth's record. [5][4][2]
- **Telehealth**: Follows the Virginia Medicaid (DMAS) rule: initial assessments must be conducted in person with the youth and the family or caregivers. Beyond that, coverage of services delivered by telemedicine is governed by the Telehealth Services Supplement to the Mental Health Services manual, and the use of telemedicine must be documented in the ISP submitted with both the initial and the continued-stay authorization. Care coordination, data analysis and treatment-plan activities billed under 97151 or 97155 do not have to be provided face to face. MCO-contracted providers must consult their contracted MCO for that plan's telehealth policies. [4][5][2]
- **Prior-auth decision time**: Virginia Medicaid rule, applied by Sentara Community Plan: since January 1, 2026 DMAS requires FFS and every Cardinal Care MCO to decide standard (non-urgent) requests within 7 calendar days of receipt and expedited requests within 72 hours; the 7-day clock can extend up to 14 calendar days if the member or provider asks, or if the extra time is justified in the member's interest to obtain more medical evidence. Sentara's 2026 manual states the same: standard decisions "not to exceed seven calendar days following receipt of the request for service," expedited "no later than 72 hours after receipt of the request." Timing from Appendix D: submit treatment requests (initial and continued stay) by the requested start date — "If submitted after the required time-frame, the begin date of authorization will be based on the date of receipt," so a late reauthorization leaves an unpaid gap. [7][8][4][9]
- **Other insurance (who pays first)**: Medicaid pays last. Sentara's manual: "If a Sentara Health Plans program member is identified as having a commercial product, the provider must send the initial claim to the commercial plan for payment… Medicaid is always the payor of last resort." Sentara is the one Virginia MCO that writes down the secondary-authorization rule: "Sentara Health Plans does not require service authorization when acting as the secondary payer except" when the primary payer does not cover the service, or the member has exhausted the primary's benefit — in either case Sentara becomes the primary payer and its service authorization is required. So: covered by the commercial plan → the commercial plan's authorization, no Sentara SA; commercial plan excludes ABA or the benefit is used up → Sentara SA before services. TRICARE and CHAMPVA both pay ahead of Medicaid: TRICARE rules state "Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer," and CHAMPVA "assumes primary payer status" over Medicaid. [7][5][10][11]

## Delivery and billing rules

Coverage decides whether Sentara Community Plan (VA) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Follows the Virginia Medicaid (DMAS) rule: three separate floors. The LBA, LABA or LMHP must at a minimum observe the youth and supervise services monthly, with supervision documented as a review of progress notes and data plus dialogue with supervised staff about progress and the effectiveness of the ISP. Supervision of unlicensed staff must occur at least twice a month by the LBA, LABA or Licensed Clinical Psychologist, demonstrated by the contemporaneously dated signature of the licensed supervisor. Clinical supervision is required for services rendered by an LABA, LMHP-R, LMHP-RP or LMHP-S, consistent with the scope of practice set by the applicable Virginia Department of Health Professions board — on the nature of supervision DMAS defers to that board and to the BACB. Supervision time without the individual present is not billable; the technician rates were built to include it. [4][5][2]
- **Concurrent billing (97153 + 97155)**: Follows the Virginia Medicaid (DMAS) rule: Appendix D publishes the combinations that may be billed at the same time: 97152 with 97151 (except 97152 HN together with 97151 HN); 97153 with 97155 (except 97153 HN together with 97155 HN) — DMAS adds that 97155 and 97153 may be billed together for supervision activities when the QHP is directing the technician in delivering treatment and the QHP, technician and youth are all present; 97154 and 97158 at the same time for different youth in the same group, with identical professional-level modifiers; 97153 at the same time for two technicians when the reason is documented in a service-authorized ISP; and services with the youth alongside family or group family training when delivered by different qualified staff. What is barred: an additional technician-level code alongside 97158 or 97154. Separately, ABA may not be authorized concurrently with Intensive In-Home, Mental Health Skill Building, Psychosocial Rehabilitation, Partial Hospitalization or Assertive Community Treatment, though short-term authorization overlaps are allowed during transitions. [4][5][2]
- **Daily limits / MUEs**: Follows the Virginia Medicaid (DMAS) rule: no per-day unit ceiling. Assessment codes 97151, 97152 and 0362T carry no service authorization and no unit limit, but may only be billed as part of an initial assessment or a full reassessment. Since dates of service 10/15/2025 every treatment code is authorized with its own predetermined number of units rather than bundled under 97155. Requests at or above 20 hours (80 units) a week must include an individualized schedule of activities that distinguishes therapeutic from recreational time — a general schedule of clinic-based activities is not sufficient. Group sizes follow CPT guidelines. In Residential Treatment Services settings, including therapeutic group homes and PRTFs, the payable ABA set narrows to 97151, 97154 (with modifier HN, HO or TF only), 97155, 97156 and 97157. Sentara was the first plan to post the DMAS units-per-code preservice form, for dates of service 9/1/2025 onward, ahead of the statewide 10/15/2025 mandate; its worked example models 2 hours a day across 5 days for 24 weeks, which puts roughly 6-month authorization spans as the practical norm. [2][4][3]
- **Session-note signature**: Follows the Virginia Medicaid (DMAS) rule: documentation must carry the initial assessment completed by the LBA, LABA or LMHP including the assessment instruments used, dates of service and face-to-face contacts, staff and participant names, and staff credentials and signatures. Treatment progress must be documented through daily data collection plus a weekly summary note, with graphical analysis of goals and objectives for those dates of service. Supervision is demonstrated by the contemporaneously dated signature of the licensed supervisor. The ISP must be reviewed at least every 30 calendar days — a progress note satisfies the review if it documents the discussion, any alterations, and the individual's response; the individual's signature is not required, and the 30-day review is held for audit rather than submitted. [4][5][2]
- **Place of service**: Follows the Virginia Medicaid (DMAS) rule: ABA may be provided in home or community settings where the targeted behaviors are likely to occur, and in clinic settings — the setting must be justified in the ISP. School is the constrained one: ABA may only be provided in the school setting when the purpose is observation and collaboration by the QHP related to behavior and skill acquisition, not direct therapy, and only when authorized by the school, the parent and the provider and included in the ISP. Technician-level codes may not be billed for school observation and collaboration, and DMAS interprets school as any education setting, private or public; additional school ABA may be available under school health services through the local education agency. Services rendered primarily by a relative or guardian who is legally responsible for the youth's care are not covered. [4][5][2]
- **Bill as provider**: Follows the Virginia Medicaid (DMAS) rule: ABA providers must be enrolled with DMAS under the ABA provider types (PCT 156 or 456 with PS 903; PCT 020 or 023; PCT 256 with PS 104), licensed by the applicable Virginia Department of Health Professions board, and credentialed with the youth's Medicaid MCO for managed-care members. Every CPT code is billed with the staff modifier that identifies the professional providing the service: HN for an LABA, HO for an LBA, TF for an LMHP. QHP-level codes must be provided by an LBA or LMHP, with an LABA able to act as a QHP as determined by the supervising LBA under 18VAC85-150-120, and LMHP-Rs, LMHP-RPs and LMHP-Ss with completed ABA education and training able to provide them under the supervising LMHP. Technician-level codes may be delivered by an LMHP-R/RP/S under supervision, an LABA under an LBA, personnel supervised by an LBA or LABA under 18VAC85-150-10 et seq., personnel supervised by a Licensed Clinical Psychologist under § 54.1-3614, or by an LBA or LMHP acting as the technician — LBAs may bill technician-level codes with the appropriate modifier. Unlicensed personnel include but are not limited to RBTs; Virginia does not require the RBT credential. Sentara runs supervisor changes as paperwork rather than a new authorization: it maintains a dedicated BCBA Change Request Form (updated 3/2026), which is the opposite of the NPI-matching rule at Aetna Better Health. [2][4]

## What intake should collect for Sentara Community Plan (VA)

- **ASD diagnosis:** Then book the assessment — no authorization needed on assessment codes.
- **Units per CPT code:** Sentara's form is the units-per-code template — plan intensity code by code.
- **Weekly schedule (if ≥20 hrs):** The 80-unit threshold triggers the activity-schedule requirement, embedded in the form.
- **Supervising BCBA on file:** Use the BCBA Change Request Form when supervision changes — don't let claims hit a stale name.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Sentara Community Plan (VA) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 002478 — pVerify 002478 = "SENTARA HEALTH PLANS" (Medical, Eligibility=Yes); legacy "Optima/Sentara" 00310 also exists. Directory entries under "Optima" are stale.
- **Payer ID (Availity):** 54154 — Payer ID 54154 per the DMAS Sentara MCO Directory (2025-10-29); corroborated by the 2012 Availity row "OPTIMA HEALTH PLAN → 54154."
- **Payer ID (Change Healthcare / Optum):** 54154 — Payer ID 54154 per the DMAS Sentara MCO Directory; legacy Virginia Premier (VP) group runout claims go to CHC ID VAPRM.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none (DMAS pass-through; Sentara Health Plans administers ABA in-house)
- **BH administrator payer ID:** 54154
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required — DMAS rule: assessment codes 97151, 97152, 0362T need no service authorization | No hard cap — EPSDT medical necessity governs; comprehensive assessment typically authorized in a bounded window per the treatment request per n/a (no SA on assessment codes) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy (initial assessment must be conducted in person). | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97152 | Yes | Not required — DMAS rule: assessment codes 97151, 97152, 0362T need no service authorization | No hard cap — EPSDT medical necessity governs; comprehensive assessment typically authorized in a bounded window per the treatment request per n/a (no SA on assessment codes) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy (initial assessment must be conducted in person). | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97153 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97154 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97155 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97156 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97157 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97158 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 0362T | Yes | Not required — DMAS rule: assessment codes 97151, 97152, 0362T need no service authorization | No hard cap — EPSDT medical necessity governs; comprehensive assessment typically authorized in a bounded window per the treatment request per n/a (no SA on assessment codes) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy (initial assessment must be conducted in person). | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 0373T | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |

Code notes:

- **97151:** Behavior-identification assessment (QHP). No service authorization — book the assessment on an ASD diagnosis; build the treatment request from it.
- **97152:** Supporting assessment (technician-adjunct). No service authorization.
- **97153:** Direct one-on-one adaptive-behavior treatment by a technician. Per-code units on the preservice form since 10/15/2025.
- **97154:** Group adaptive-behavior treatment. SA required.
- **97155:** Adaptive-behavior treatment with protocol modification (QHP). SA required; billable alongside 97153 when the QHP directs face-to-face.
- **97156:** Family adaptive-behavior treatment guidance (QHP). SA required.
- **97157:** Multiple-family group guidance. SA required.
- **97158:** Group adaptive-behavior treatment with protocol modification. SA required.
- **0362T:** Behavior-identification supporting assessment (extended/destructive-behavior). No service authorization under the DMAS baseline (note: Humana Healthy Horizons flags 0362T as PA-required — see that guide).
- **0373T:** Extended/destructive-behavior treatment protocol (extra-technician). SA required.

### Medicaid rates

Source: DMAS CPT fee file (cptmedical4.csv for 97151–97158; cptmedical1.csv for 0362T/0373T), read directly from the live file: licensure-tiered per-15-minute ABA rates effective 12/01/2021 (end 12/31/9999), still current in the file that also carries 07/01/2026 rows. Tiers flagged by modifier: no modifier = technician, HN/U1 = LABA, TF/U2 = LMHP, HO/U3/U7 = LBA; ABA rows are the OP (outpatient) place-of-service lines. Trap (confirmed): the file also carries generic "REGULAR & CSB" IP rows for 97151/97152/97156/97157 at a few dollars per unit (e.g. 97151 IP $6.75) — those are the non-ABA physician-fee lines, NOT the ABA program rates. Modifier definitions cross-checked against VirginiaABA's (draft) DMAS billing guidance. No Sentara Community Plan-specific ABA fee schedule is publicly posted; the 5 Cardinal Care MCOs run identical DMAS criteria and standardized forms but are not required to match the FFS schedule — this table is the DMAS reference baseline, not a plan-confirmed paid rate. Effective 2021-12-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97152 | $15.00 (technician) / $23.48 (LABA) | 15min | technician: $15.00; HN (LABA): $23.48 |
| 97153 | $15.00 (technician) | 15min | technician: $15.00; HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97154 | $12.77 (technician) — group | 15min | technician: $12.77; HN (LABA): $15.60; TF (LMHP): $13.13; HO (LBA): $15.55 |
| 97155 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97156 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97157 | $7.83 (LABA) / $13.13 (LMHP) / $15.55 (LBA) — multi-family group | 15min | HN (LABA): $7.83; TF (LMHP): $13.13; HO (LBA): $15.55 |
| 97158 | $22.83 (LABA) / $28.13 (LMHP) / $30.54 (LBA) — group w/ protocol mod | 15min | HN (LABA): $22.83; TF (LMHP): $28.13; HO (LBA): $30.54 |
| 0362T | $53.47 (LABA) / $69.39 (LMHP) / $76.62 (LBA) — team supporting assessment | 15min | HN (LABA): $53.47; TF (LMHP): $69.39; HO (LBA): $76.62 |
| 0373T | $53.47 (LABA) / $69.39 (LMHP) / $76.62 (LBA) — team treatment | 15min | HN (LABA): $53.47; TF (LMHP): $69.39; HO (LBA): $76.62 |

### Contacts

- **Provider services phone:** 757-552-7174 or 1-800-648-8420 (Behavioral Health Provider Services)
- **Hours:** 8 a.m.-6 p.m. Monday-Friday (Medicaid line)
- **Portal:** [Availity](https://www.availity.com)
- **Fax:** 757-552-7499 (Behavioral Health)

Questions to ask on a verification call:

- What places of service are approved under this member's authorization — home, school, community, or telehealth?
- Does Sentara Community Plan pay these ABA codes at the DMAS fee-schedule rate, or is there a plan-specific contracted rate?

### VOB data sources

- https://shc-p-001.sitecorecontenthub.cloud/api/public/content/c4fe04b9052647fb8655708609cc9e7f?v=4adf8dd1 (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://vamedicaid.dmas.virginia.gov/sites/default/files/2026-07/MES%20EDI%20270-271%20Companion%20Guide_R100_20220509-PK%202.pdf (accessed 2026-07-23)
- https://vamedicaid.dmas.virginia.gov/sites/default/files/2025-07/MHS%20-%20Appendix%20D%20(updated%207.17.25)_Final.pdf (accessed 2026-07-23)
- https://www.dmas.virginia.gov/media/4271/project-bravo-services-faqs-aba.pdf (accessed 2026-07-23)
- https://vamedicaid.dmas.virginia.gov/bulletin/service-authorization-update-applied-behavior-analysis-aba-effective-october-15-2025 (accessed 2026-07-23)
- https://www.dmas.virginia.gov/media/cptcodes/cptmedical4.csv (accessed 2026-07-23)
- https://www.dmas.virginia.gov/media/cptcodes/cptmedical1.csv (accessed 2026-07-23)
- https://virginiaaba.org/wp-content/uploads/2021/11/ABA-Billing-Guidance-from-DMAS-Nov21.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.sentarahealthplans.com/en/providers/contact-us (accessed 2026-07-23)

## Common questions

### Does Sentara Community Plan cover ABA?

Yes — Virginia's Cardinal Care ABA benefit on DMAS criteria and forms: no authorization on assessment codes, treatment authorized with units per CPT code on the new DMAS preservice form.

### Is Optima Family Care the same as Sentara Community Plan?

Yes — Optima Family Care and Virginia Premier merged into Sentara Community Plan under the Cardinal Care rebrand. Anything still labeled Optima is stale.

### How do I change the supervising BCBA on a Sentara authorization?

Use the plan's dedicated BCBA Change Request Form (updated March 2026) — a standing administrative workflow rather than a new authorization.

## Primary sources

1. [Sentara — BH prior authorization forms (government plans)](https://www.sentarahealthplans.com/en/providers/claims-authorizations/authorizations/behavioral-health/government)
2. [Sentara — DMAS ABA preservice SA form (DOS 9/1/2025+)](https://shc-p-001.sitecorecontenthub.cloud/api/public/content/c4fe04b9052647fb8655708609cc9e7f?v=4adf8dd1)
3. [DMAS — ABA service authorization update (eff. 10/15/2025)](https://vamedicaid.dmas.virginia.gov/bulletin/service-authorization-update-applied-behavior-analysis-aba-effective-october-15-2025)
4. [DMAS — MHS manual Appendix D (ABA)](https://vamedicaid.dmas.virginia.gov/sites/default/files/2025-07/MHS%20-%20Appendix%20D%20(updated%207.17.25)_Final.pdf)
5. [DMAS — Project BRAVO ABA FAQ](https://www.dmas.virginia.gov/media/4271/project-bravo-services-faqs-aba.pdf)
6. [Sentara — BH authorization fax numbers and forms update (eff. 8/1/2025)](https://www.sentarahealthplans.com/en/providers/updates/behavioral-health-authorization-fax-numbers-and-forms)
7. [Sentara Health Plans — Virginia Medicaid Program Provider Manual (2026)](https://shc-p-001.sitecorecontenthub.cloud/api/public/content/166702e707ad4460995f61992a6be8e0?v=2c7ff490)
8. [DMAS bulletin — Interoperability and Prior Authorization Final Rule implementation update](https://vamedicaid.dmas.virginia.gov/bulletin/interoperability-and-prior-authorization-final-rule-implementation-update)
9. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
10. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
11. [38 CFR 17.272 — CHAMPVA benefit limitations; Medicaid exception (eCFR)](https://www.ecfr.gov/current/title-38/section-17.272)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.