Below are Priority Health's medical claims payment policies. This information may help providers bill claims more accurately to reduce delays in processing, as well as avoid rebilling and additional requests for information.
A
- Acupuncture
- Advance care planning (ACP)
- Add-on codes
- After hours and weekend care professional
- Advanced Practice Professional (APP)
- Allergy injection and immunotherapy
- Always / sometimes therapy
- Ambulance services
- Ambulatory surgical centers
- Anesthesia
- Arthrocentesis, Aspiration, Injection
- Autonomic function testing
B
- Balance billing
- Balloon sinus ostial dilation for chronic sinusitis and eustachian tube dilation
- Bariatric surgery for treatment of co-morbidities and conditions related to morbid obesity
- Behavioral health
- Bladder scans
- Blepharoplasty, blepharoptosis and brow lift
- Blood glucose monitors / continuous glucose monitors
- Botulinum toxin type A & type B
C
- Capsule endoscopy
- Cardiac rehabilitation
- Cardiology
- Cardiovascular disease risk assessment
- Care management services
- Cataracts
- Cervical traction devices
- Chiropractic services
- Chronic pain management services
- Claim submission guidelines
- Clinical edit
- Clinical trials
- Colorectal cancer screening
- Compression garments
- Concierge medicine
- Condition codes
- Critical access hospital (CAH) method II billing
- Critical care
D
- Diabetes education
- Distinct unbundled modifiers
- Drug testing
- Drugs administered by providers for FDA-approved or medically accepted off-label uses
- Duplicate claims
- Durable medical equipment (DME) capped rental
- Durable medical equipment (DME) / prosthetics & orthotics modifiers
- Durable medical equipment (DME) place of service (POS)
- Durable medical equipment (DME) refill requirements
- Durable medical equipment (DME) repair and replacement
E
- ECG interpretation
- Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)
- E/M services billed with treatment room codes
- Endomyocardial biopsy with right heart catheterization
- Enteral nutrition
- Epidural steroid injection for pain management (ESI)
- Evaluation and management
- Excludes1
F
- Facility modifiers
- Flow cytometry
- Foot care and onychomycosis testing
- Frequency of care coordination services and ESRD procedures
- Frequency of hemodialysis
- Fundus photography
G
H
- High-level E/M with preventive exam
- High tech radiology services
- HIV prognosis and monitoring
- Home health
- Home infusion
- Home prothrombin time or INR monitoring
- Hospice care
- Hypoglossal nerve stimulation for treatment of obstructive sleep apnea
I
- Incidental services and supplies
- Infusion services supplies
- Inpatient only procedures
- Intraoperative neurophysiological testing
J
K
L
M
- Magnetoencephephalography (MEG)
- Malnutrition
- Maternity and prenatal care
- Medicare Annual Wellness Visit (AWV) / preventive care visits
- Mechanical vent and length of stay
- Micro-invasive glaucoma surgery
- Miscellaneous DME
- Miscellaneous DME supplies
- Moh's micrographic surgery
- Musculoskeletal shoulder
- Musculoskeletal spine
N
- Nebulizers
- Negative pressure wound therapy pumps
- Nerve conduction / EMG
- Non-invasive peripheral arterial vascular studies
- Nutrition counseling, education and therapy
O
- Observation stays
- Once per lifetime
- Ophthalmology and vision
- Ordering / referring provider requirements
- Osteogenesis
- Osteopathic manipulation treatment (OMT)
- Ostomy supplies
- Oxygen and oxygen supplies
P
- Paid amount exceeds billed amount
- Panniculectomy / Abdominoplasty
- Partial Hospitalization Program (PHP)
- Pelvic and transvaginal ultrasound
- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
- Polysomnography and sleep studies
- Portable radiology services
- Positive airway pressure (PAP) devices for treatment of sleep apnea
- Preoperative testing
- Preventive services
- Professional and technical components status indicator
- Professional status indicator
- Prostate biopsy pathology
- Prosthetic orthotics and footwear
- Provider-based billing
- Psychiatry and Psychology services
- Pulmonary function testing
R
- Radiation oncology
- Radiology PC / TC multiple same-day billing
- Readmissions reimbursement
- Removal of benign skin lesions
S
- Sacroiliac joint injections and procedures
- Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
- Semiprivate vs private room
- Sepsis
- Site neutral medical drug
- Skilled nursing / Non-inpatient services
- Smoking cessation
- Split billing
- Surgical dressings
- Surgical implants & devices
T
- Three-day window bundling
- Tracheostomy care supplies
- Transcranial magnetic stimulation (TMS)
- Transcutaneous electrical joint stimulation devices
- Trauma team activation
- Treatment rooms
U
- Unlisted codes
- Upper limb stimulation for the treatment of tremors
- Urinary tumor markers for bladder cancer
- Urological supplies