We publish billing policies to offer transparency and help providers to bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.
The following billing policies were recently published to or updated in our Provider Manual.
Be sure to review carefully. Some policy updates will be effective Nov. 16, 2026, due to new requirements or changes that may impact how you work with us.
All other policies represent our current system set up and/or expectations for transparency. There are either no changes for providers as the policy is already in effect or the policy was recently shared with the network and we’re implementing a clinical edit in alignment with the policy’s language.
| Billing policy | Description | Effective date |
|---|
| New policies |
| Expanded Carrier Screening Genetic Tests - #207 | - Created a new billing policy based on information found in the Priority Health Provider Manual
| N/A |
| Updated policies |
| Blood Counts - #184 | - Removed medical necessity criteria.
- Clarified language related to preventive services and provided a link to the Preventive Services page in our Provider Manual.
- Added Policy Overview section
| N/A |
| Blood Glucose Monitors / Continuous Glucose Monitors - #059 | - Added: “Priority Health requires billing HCPCS codes A4238 and A4239 for continuous glucose monitoring (CGM) equipment and supplies. These codes include all associated supplies and accessories. Billing of HCPCS codes A9276, A9277, and A9278 is not allowed and will be denied.”
| Nov. 16, 2026 |
| Capsule Endoscopy - #112 | - Added “Refer to Medical Policy 91476 for applicable diagnosis requirements and medical necessity criteria” to the Coding Specifics section
| N/A |
| Colorectal Cancer Screening - #121 | - Added Policy Overview section
- Added Coding Specifics section
- Cologuard: Removed age range and frequency; added instructions for accessing clinical guidelines; added authorization language
- Cologuard Plus: Added age range and frequency; removed authorization language
- Shield: Removed authorization language; added instructions for accessing clinical guidelines
| N/A |
| Cosmetic & Reconstructive Surgery - #197 | - Added Policy Overview and Definitions sections
- Under Coding Specifics, removed Z41.8 as a code that excludes coverage for any service
- Added language for Modifiers, Place of Service and Documentation Requirements
- Removed the heading, “The following CPT codes and procedures are cosmetic and will not be covered,” adding the indicated codes to the table above, “The following CPT codes and procedures are generally considered cosmetic and may be reviewed or denied as non-covered services”
| N/A |
| Facility Rate Change Letters - #178 | - Added Policy Overview section
- Updated rate letter submission guidelines
| N/A |
| Facet Joint Interventions for Pain Management - #142 | - Removed limits to diagnostic joint sessions and paravertebral facet joint injections from the Reimbursement Specifics section
- Removed medical necessity criteria from the Billing Details section
- Put CPT codes into table format
| N/A |
| Osteogenesis - #104 | - Corrected language for the KF modifier, per CMS Bulletin on July 1, 2026
| N/A |
| Paid Amount Exceeds Billed Amount - #105 | - Added Policy Overview section
- Added Definition section to define “lesser of” language
| N/A |
| Provider-Based Billing - #025 | The policy was updated to include: - Routine supplies and commonly packaged drugs / biologicals used during a provider-based visit are inclusive to professional charges – these should not be reported on a separate facility claim.
- Clarification that treatment rooms or specialty services are inclusive to professional charges for provider-based visits.
- Specific revenue codes that will no longer be payable on facility claims when used in conjunction with clinic / provider-based visit services.
| Nov. 16, 2026 |