Medical policy updates

Below are links to updated, or new policies. Remember, you can always find the latest updates to policies in the Medical Policies section of the Provider Manual.

Genetics: Counseling, Testing and Screening – 91540

Effective immediately, Genetics: Counseling, Testing and Screening policy requires prior notification for inpatient Rapid Whole Genome Sequencing (rWGS). Prior notification may occur prior to or in conjunction with testing.

The policy change only affects the commercial plan. Rapid Whole Genome Sequencing (rWGS) is not a covered benefit for Priority Health Medicaid or Medicare members.

Effective April 1, 2019

Continuous Glucose Monitoring – 91466

Effective April 1, 2019, Priority Health will begin coverage of personal use continuous glucose monitoring systems (CGMSs) for Medicaid members. Prior authorization is required of all ages, including infants and toddler (age 5 and under). The request for authorization for all ages is to ensure standards of coverage and documentation requirements are met.

Effective May 1, 2019

Clinical Trials – 91606

Effective May 1, 2019, the prior authorization requirement for drug-related clinical trials for Priority Health commercial and Medicare Advantage members have been removed.  Instead, in-network providers will need to inform us that the member is participating in a clinical trial via Clear Coverage.

When billing a claim to Priority Health, providers should bill the appropriate Q0 and Q1 modifier to indicate the service was part of a clinical trial. Providers must bill according to the clinical trial medical policy.

The exceptions to this rule are for out of network (non-par) providers, prior authorization is still required.

This is not a covered benefit for Medicaid.