Billing & payment news
We've made changes to our claim appeals process
We’ve made some changes to our claim disputes process to streamline options for you and align with industry best practices. We’ve also made changes to the requirements for escalating claims.
January 28, 2026
We’re reprocessing some Medicare claims impacting fee-for-service providers
We identified an error in how some Medicare fee schedule rates were loaded into our system. The base physician facility and non facility rates were accidentally reversed, impacting two fee schedules and approximately 2,000 CPT and HCPCS codes.
January 23, 2026
01/14/2026: January 2026 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.
January 14, 2026
New payment and RA processes coming Aug. 1, 2026
We’ve partnered with Optum Financial and ECHO Health, Inc. to provide payment and payment reconciliation services to you, our provider network.
January 13, 2026
New process for submitting Part D immunizations for PriorityMedicare members
Effective January 1, 2026, providers must bill Part D immunizations for PriorityMedicare Dual Premier (HIDE-SNP) members through TransactRx when vaccines are administered in a physician’s office. Claims submitted directly to us will deny as provider liability, and providers may not bill members for any vaccine costs or administration fees. The TransactRx process is available for all PriorityMedicare members.
December 10, 2025
Code 0523T not separately payable
We're correcting an issue with CPT code 0523T which was requiring a prior authorization in error. This code is not separately payable form the primary procedure for all products.
December 10, 2025
12/18/2025: December 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.
December 9, 2025
11/13/2025: November 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.
November 5, 2025
11/5/2025: Recouping care management payments from FQHC/RHC/THC
We recently discovered we’ve been paying the following transition of care codes* when billed by FQHC / RHC / THCs for Medicaid, when we shouldn’t:
November 5, 2025
11/01/2025: 2026 commercial fee schedules are available online
2026 commercial fee schedules are available online
October 29, 2025
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