Billing & payment news
10/28/2025: Reimbursement requirements for outpatient medical drugs
Effective Jan. 1, 2026, for commercial plans, certain drugs covered under the medical benefit and administered in an outpatient hospital setting – whether in-network or out-of-network – must be dispensed and billed directly by a specialty pharmacy that Priority Health has a reimbursement agreement with.
October 20, 2025
We'll no longer be paying for certain HCPCS codes per CMS guidelines
Several Home Health HCPCS G-codes were created by CMS to collect data on telehealth for Home Health, which some providers had previously billed for. We’ll no longer be paying these claims separate from the home health visit for any product, effective December 16, 2025:
October 8, 2025
10/13/2025: October 2025 billing policy updates
We publish billing policies to offer transparency and help you bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.
October 7, 2025
9/25/2025 Provider news: Reprocessing incorrectly rejected Medicaid claims
We recently experienced an issue with some Medicaid claims containing drug-related lines being front-end rejected for “Missing/Invalid NDC” when they shouldn’t.
September 25, 2025
09/15/2025: September 2025 billing policy updates
We publish billing policies to offer transparency and help you bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.
September 12, 2025
9/4/2025: Reprocessing claims incorrectly rejected for Medicaid edit 1462
We recently experienced a brief issue with some Medicaid claims being front-end rejected for “Missing/Invalid NDC” when they shouldn’t.
September 4, 2025
August 2025 billing policy updates
The following billing policies were recently published to or updated in our Provider Manual’s Billing Policies page.
August 8, 2025
Fee schedule change for non-physician Medicaid behavioral health services
Effective Oct. 1, 2025, our standard Medicaid reimbursement for all non-physician behavioral health providers (i.e., LP, LMSW, LPC, LLP, LMFT) will align with industry standards and be based on MDHHS’ Non-Physician Behavioral Health Fee Schedule, rather than the Practitioner/Medical Clinic Fee Schedule currently used.
July 10, 2025
Billing policy reminders
We’re reminding our provider network about several billing policies and requirements as we’ll soon implement clinical edits in alignment with the outlined information.
July 7, 2025
July 2025 billing policy updates
The following billing policies were recently published to or updated in our Provider Manual’s Billing Policies page.
July 2, 2025
Medicare therapy cap changes effective Jan 1 2025
Starting Jan. 1, 2025, we're changing our Medicare therapy caps for physical, occupational and speech therapies (PT/OT/ST) to align with recent CMS guideline updates.
June 29, 2025
New and updated billing policies
We’ve posted several new and updated billing policies, which align to industry standards, to the Provider Manual.
June 29, 2025