August 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.

The following billing policies were recently published to or updated in our Provider Manual’s Billing Policies page.

Note: If the effective date is listed as N/A, the policy represents our current system set up and/or expectations for transparency. There are either no changes for you as the policy is already in effect or was recently shared with the network and we’re implementing a clinical edit in alignment with the policy’s language.

Billing policyNew or updatedDescriptionEffective date
AcupunctureUpdatedThis policy was created using existing content from the Priority Health Provider Manual, with the addition of standard documentation and billing criteria guidelines.N/A
Ambulance servicesUpdatedThis policy was created using existing content from the Priority Health Provider Manual, with the addition of related denial language for a clinical edit that’s already in place.N/A
Balloon sinus ostial dilation for chronic sinusitis and eustachian tube dilationNewThis new policy outlines our existing requirements and criteria.N/A
Bariatric surgery for treatment of co-morbidities and conditions related to morbid obesityNewThis new policy outlines our existing requirements and criteria.N/A
Blood glucose monitors / continuous glucose monitorsNewThe new policy combines CGM and BGM information into one policy and establishes limits for diabetic monitors and supplies.Oct. 20, 2025
Cardiovascular disease risk assessmentNewThis new policy outlines our existing requirements and criteria.N/A
Care managementUpdatedAdded information for code G0506: not covered under commercial or Medicaid. Covered once per year under Medicare.Oct. 20, 2025
CataractsUpdatedThis policy was created using existing content from the Priority Health Provider Manual.N/A
Colorectal cancer screeningNewThis new policy outlines our existing requirements and criteria.N/A
Continuous glucose monitorsRetiredThis billing policy is being retired and the information it contains will be transferred to the new Blood Glucose Monitors / Continuous Glucose Monitors policy.N/A
Drug testingUpdatedClarified a non-covered criteriaN/A
Drugs administered by providers for FDA-approved or medically accepted off-label usesUpdatedAdded examples of drugs and biologicals aligned to the policy criteria; added related claim denial languageN/A
Evaluation and managementUpdatedUpdated the related denial language section to include an existing clinical editN/A
Frequency of care coordination services and ESRD proceduresNewThis new policy outlines the billing and payment requirements for care coordination and ESRD services – indicating that care coordination is included in ESRD monthly services.Oct. 20, 2025
Frequency of hemodialysisNewThis new policy outlines the billing and payment requirements for line item billing dialysis sessions for end stage renal disease (ESRD) patients.Oct. 20, 2025
Genetic testing, counseling and screeningUpdatedAdded information on genomic sequencing, PLA and multianalyte assays, in alignment with CMSN/A
High tech radiology servicesUpdatedAdded radiopharmaceutical and contrast material coding and billing informationN/A
Home healthUpdatedUpdated to reflect the removal of prior authorization requirements for services provided by home health agenciesN/A
Home prothrombin time or INR monitoringNewThis new policy outlines our existing requirements and criteria.N/A
Hypoglossal nerve stimulation for the treatment of obstructive sleep apneaUpdatedAdded secondary diagnosis sequencing requirementOct. 20, 2025
Infusion services suppliesUpdated

Additions:

  • In the event that multiple visits occur on the same date of service, suppliers must only bill for one visit and should report the highest paying visit with the applicable drug. Claims reporting multiple visits on the same line item date of service will be returned
  • Professional services section
N/A
Intraoperative neurophysiological testingNewThis new policy outlines our existing requirements and criteria.N/A
JA / JB modifiersNewThis new policy outlines billing requirements for use of the JA and JB modifiers.Oct. 20, 2025
Knee arthroscopyNewThis new policy provides transparency around coding rules and documentation requirements.N/A
Lab and pathologyUpdatedAdded billing information related to celiac disease testingN/A
Nerve conduction / EMGNewThis new policy outlines our existing requirements and criteria.N/A
Panniculectomy / AbdominoplastyNewThis new policy outlines our existing requirements and criteria.N/A
Preoperative testingNewThis new policy outlines our existing requirements and criteria.N/A
Prosthetic orthotics and footwearUpdatedAdded our existing requirements and criteria for spinal orthosesN/A
Pulmonary function testingNewThis new policy outlines our existing requirements and criteria.N/A
Skilled nursing / Non-inpatient servicesUpdatedAs medical policy #91332 will soon be retired, we’ve added details from the medical policy into this billing policy and updated the billing policy title to encompass non-inpatient services.N/A
Smoking cessationUpdatedThis policy was created using existing content from the Priority Health Provider Manual.N/A
Transcranial magnetic stimulation (TMS)UpdatedThis policy was created using existing content from the Priority Health Provider Manual.N/A