Sentara Issues Cross-Year Maternity Billing Guidance for 2027

In its September 3, 2026 provider update, Sentara Health Plans now instructs providers to use 59425 or 59426 for members receiving maternity care in 2026 whose delivery will occur after January 1, 2027. Additional Sentara implementation guidance will follow. See the Sentara provider update for the original notice.

Why This Notice Is Operationally Important

This guidance differs from payers that are already beginning early E/M-plus-TH billing for 2026 antepartum care. Sentara's notice also omits several details that providers will need before implementation:

• Applicable product lines
• Treatment of one to three 2026 visits
• Modifier requirements
• Reimbursement for the new codes

AMA's Controlling CPT Transition Guidance

Absent further Sentara detail, providers can look to the AMA transition FAQ for the framework Sentara's instruction sits within:

• Individual E/M codes, 1 to 3 antepartum visits 2026. 
• Four to six visits: 59425.
• Seven or more visits: 59426.
• Report 59425/59426 when the represented service concludes, generally using the final included encounter date.
• All 2027 antepartum encounters: individual E/M codes.

Scope Considerations

The notice by Sentara does not expressly restrict the instruction by product. It is offered to Virginia Medicaid/FAMIS and commercial plans, so it is important to verify its applicability prior to payer-wide deployment. 

How Does BillingFreedom Support Sentara OB/GYN Billing?

Cross-year maternity billing becomes challenging when payer instructions do not follow the same transition model. BillingFreedom uses OBGYN Medical Billing workflows to separate Sentara claims from payers using E/M-plus-TH billing, helping practices apply the correct strategy before claims reach the payer.

Build Payer-Specific Billing Scenarios

BillingFreedom can set up unique billing situations for Sentara members according to expected delivery period, number of Sentara antepartum visits and the 2026 maternity timeline. This will make it impossible for staff to automatically use another Payer's 2027 transition rules when processing Sentara claims. 

Track Antepartum Visits Before Submission

Depending on the number of antepartum visits that a patient has, 59425 and/or 59426 may be appropriate. BillingFreedom can monitor the steps taken for the visit workflow and high-risk claims prior to submission. 

Create Exception-Based Claim Reviews

When Sentara’s guidance does not address a specific scenario, such as one to three 2026 visits or an unidentified product line, BillingFreedom can route the claim for payer-specific review rather than allowing an assumption-based claim to enter the submission queue.

For OBGYN practices, the goal is to use a payer bulletin as a blueprint for a controlled billing process that works for each individual payer. BillingFreedom's Medical Billing support for OBGYN practices can guide them through payer-specific scenarios related to maternity, detect exceptions before claims are submitted and adjust claims tactics as Sentara publishes more guidance. 

To learn more about our outstanding medical billing services, you may not hesitate to get in touch with us through email at info@billingfreedom.com or by phone at +1 (855) 415-3472. 

Our priority is your financial peace of mind!

What This Means for Your Practice

• If you bill Sentara, use 59425 or 59426 for 2026 antepartum care on patients delivering after January 1, 2027. That is what the September 3 notice asked for, effective immediately.
• Do not apply that rule to your other payers. Indiana and New York Medicaid want E/M plus TH for the same period.
• Keep a payer-by-payer cross-year grid: payer, instruction, effective date, source link. The grid is the control; one notice is not.
• For a Sentara patient with one to three 2026 visits, ask Sentara before billing. The notice does not cover it.
• Watch the Sentara provider updates page for the product lines, modifier requirements and reimbursement the notice leaves open.