New and updated billing policies are now available
We publish billing policies to offer transparency and help you:
- ✔ Bill claims more accurately
- ✔ Reduce delays in processing claims
- ✔ Avoid rebilling and additional requests for information
The following billing policies were recently published to or updated in our Provider Manual.
Note: If the effective date is listed as “N/A”, the policy represents our current system set up and expectations for transparency, represents no change for you and is already in effect.
Policy
New or updated
Description
Effective date
Advanced Practice Professional (APP)
Updated
In alignment with CMS billing updates that went into effect on Dec. 1, 2024, we added billing requirements for APPs in multi-specialty groups, applicable to Medicare plans.
Dec. 1, 2024 (retroactive)
After Hours and Weekend Care Professional
Updated
Added the place of service requirements for codes 99050 and 99051 for transparency into which settings are appropriate for these codes.
N/A
New
This policy expands upon the Excludes1 billing information previously shared in our Provider Manual. It offers additional information and examples. There’s no change to how providers work with us now or how they’re reimbursed.
N/A
Inpatient and Outpatient Incidental Services and Supplies Policy
Updated
Renamed the “Unbundling” policy and updated references throughout from “unbundling” to “incidental services and supplies”.
N/A
New
This policy outlines frequency limits, coding and documentation requirements for nebulizers. Providers should closely review the timing associated with appropriate billing for each code.
Apr. 21, 2025
Urinary Tumor Markers for Bladder Cancer
New
This policy outlines frequency limits, coding and documentation requirements for bladder cancer tests. Providers should closely review the timing associated with appropriate billing for these tests.
Apr. 21, 2025
Update
Added a “Disclaimer” section to all billing policies
N/A
February 2025 medical policy updates
Our Medical Affairs Committee (MAC), comprised of Priority Health network physicians, met in February and approved a series of medical policy updates. Below is a summary of the updates made. For full information, see the medical policy changes page in our Provider Manual.
Note: Nearly all policy updates go into effect Mar. 1, 2025, except for Markers for Digestive Disorders (#91583) which will go into effect May 1, 2025.
Policy
Summary of changes
Effective date
Allergy Testing / Immunotherapy (#91037)
- Reference to the Priority Health Billing Policy entitled Allergy Injections / Immunotherapy has been added. See the billing policy for recent changes to in vitro testing.
- Sublingual immunotherapy (SLIT) SLIT tablets that have not been approved by the FDA (as opposed to all SLIT tablets), as well as all aqueous SLIT formulations, aren’t medically necessary. See Priority Health’s current Pharmacy Benefit regarding coverage for FDA-approved SLIT tablets. Change made to clarify Priority Health’s current position.
Mar. 1, 2025
Autism Spectrum Disorders (#91615)
- Equine-assisted therapies (e.g., hippotherapy, therapeutic riding) has been added as an exclusion. Note, this doesn’t represent a change but rather clarifies an existing Priority Health position.
Mar. 1, 2025
Digital Therapeutics (#91645)
- The d-Nav® System (Hygieia, Inc.) is considered medically necessary when used by adults with Type 2 diabetes as an aid in optimizing insulin management.
- Policy was restructured to specify any digital therapeutics that may be considered medically necessary (inclusions) and to exclude all other digital therapeutics not expressly named as inclusions as medically necessary.
Mar. 1, 2025
End Stage Renal Disease (ESRD): Renal Dialysis (#91526)
- Deleted a significantly shortened life expectancy from list of absolute contraindications to renal transplantation as there is no universally accepted life expectancy below which an individual is ineligible for kidney transplantation.
Mar. 1, 2025
Extracorporeal Shock Wave Therapy (ESWT) (#91527)
- Added new exclusion: low intensity ESWT for the treatment of erectile dysfunction is considered experimental and investigational. This isn’t a change in coverage.
Mar. 1, 2025
Foot Care (#91121)
- Clarification: Deleted hyaluronic acid as an example of conservative therapy.
- Clarification: Deleted specific prior authorization rules for anti-fungal agents. Deferring to Pharmacy documents for coverage and prior authorization rules.
Mar. 1, 2025
Genetics: Counseling, Testing and Screening (#91540)
- Clarification: Added criteria on multi-marker tumors panel from retired Multi-Marker Tumor Panels policy # 91609
- Added directions on how to access EviCore clinical guidelines.
Mar. 1, 2025
Hearing Augmentation (#91544)
- Added cross reference to the Digital Therapeutics medical policy # 91645
- Added new exclusion: The Buffalo Model is experimental and investigational.
Mar. 1, 2025
Infusion Services & Equipment (#91414)
- Updates to site of service criteria exceptions; added exceptions for members receiving immune checkpoint inhibitors in combination with provider-administered chemotherapy on the same day, starting doses with multiple administrations, & based on the complexity of infusion.
- Removed age exemption; exceptions are made based on the complexity of the infusion.
Mar. 1, 2025
Intraoperative Neurophysiological Monitoring (#91646)
- New medical policy
- Puts information currently available in the Priority Health Provider Manual into a medical policy. No changes were made.
Mar. 1, 2025
Laser Interstitial Thermal Therapy (LITT) (#91640)
- LITT is considered medically necessary for primary and recurrent brain tumors or relapsed brain metastases when criteria are met.
Mar. 1, 2025
Markers for Digestive Disorders (#91583)
- Proactive therapeutic drug monitoring to predict therapeutic response in the management of IBD or UC (e.g., PredictrPK IFX) isn’t medically necessary
- Methane and hydrogen breath tests are medically necessary for the diagnosis of suspected lactose intolerance. At-home breath tests (e.g., TrioSmart) are not medically necessary.
Mar. 1, 2025
Medical Management of Obesity (#91594)
- Retiring medical policy
Mar. 1, 2025
Multi-marker Tumor Panels (#91609)
- Retiring medical policy
- Moving criteria to Genetics: Counseling, Testing and Screening (#91540) policy.
- Coverage for drug therapy recommended by next-generation sequencing results shall be determined by pharmacy drug coverage policies and requirements.
Mar. 1, 2025
Neuroablation for Pain Management (#91647)
- New medical policy
- Consolidated criteria which currently exist across multiple medical policies, e.g. radiofrequency ablation (RFA) for back pain from the Spine Procedures policy # 91581.
- Address non-covered experimental & investigational procedures: cooled and pulsed radiofrequency ablation (RFA), and cryoneurolysis.
Mar. 1, 2025
Rehabilitative & Habilitative Medicine Services (#91318)
- Equine therapy (e.g., hippotherapy, therapeutic riding) is considered experimental and investigational or not medically necessary. This language was added to clarify an existing Priority Health position.
Mar. 1, 2025
Spine Procedures (#91581)
- Moved radiofrequency ablation for back pain criteria to Neuroablation for Pain Management (#91647) medical policy.
- Added a reference to Neuroablation for Pain Management (#91647) medical policy
- Added directions for providers to find TurningPoint medical necessity criteria
Mar. 1, 2025
Stimulation Therapy and Devices (#91468)
- Made additions that clarify Priority Health’s current position on electric tumor treatment fields (ETTF) devices and incontinence stimulators.
Mar. 1, 2025
Transcatheter Heart Valve Procedures (#91597)
- Utilization management and medical necessity criteria around transcatheter cardiac valve replacements and repairs have been clarified.
- Any procedures or interventions that are outside the scope of transcatheter heart valve procedures have been removed.
Mar. 1, 2025
New prior authorization requirement for cardiac procedures 92924 and C1605 effective Apr. 21, 2025
Effective Apr. 21, 2025, we’ll require prior authorization for the following cardiac procedures, for all lines of business:
- 92924: Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery or branch
- C1605: Pacemaker, leadless, dual chamber (right atrial and right ventricular implantable components), rate-responsive, including all necessary components for implantation
These procedures will be managed by TurningPoint on behalf of our members. You’ll initiate your requests in prism’s Authorizations Request Tool and will be redirected automatically to TurningPoint’s provider portal to complete the request submission.
Provider training and education pages are now in prism
All Priority Health provider training and education pages are now accessible only behind login through prism. This includes:
- Provider webinars page
- VOA Modules (short educational video content)
- Physician & practice news digest archive
- Video library
How do I navigate to these pages?
In prism, go to the Resources dropdown menu and select Training & education. This will take you to the new provider training & education landing page, where you’ll find links to each of the pages listed above.
What about provider training opportunities news and ON24?
The training opportunities and education provider news page and ON24 are still accessible without logging in, so providers without a prism account will still be able to register for and view our webinars.
Questions?
Connect with your Provider
Strategy & Solutions Consultant, Andrew Turner Jr .
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