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 policy | Description | Effective date |
|---|---|---|
| New policies | ||
| Facility rate change letters | This policy provides industry standard coding and billing information, including modifiers, definitions and the associated medical policy | NA |
| Immunizations | This policy isn’t new to Priority Health, but created from the existing Provider Manual page. | NA |
| Mammography/Tomosynthesis | This policy update includes aligning with industry standard coding and billing information, outlining modifiers, definitions and the associated medical policy. | May 19, 2026 |
| Site of Service | This policy is part of Priority Health’s broader site-of-care strategy to support affordability and access by encouraging elective outpatient procedures to be performed in clinically appropriate lower-acuity settings. Our goal is to help ensure our members receive the right care, at the right place, at the right price. At this stage, the policy provides guidance to the network on site-of-care expectations. Priority Health may implement controls in the future to support these expectations. If that occurs, we will provide advance notice. | May 19, 2026 |
| Technical Denials | This policy in being introduced in line with industry standards to increase payment accuracy by confirming that payments are only made for services supported by coverage, coding, and medical necessity requirements. | May 19, 2026 |
| Updated policies | ||
| After hours and weekend care (professional) | We’ve updated this policy to specify that after hours care is not appropriate in POS 20 or when the specialty type is Urgent Care. Claims with POS 20 or specialty Urgent Care will be denied. | May 19, 2026 |
| Enteral Nutrition | This policy update includes aligning with industry standard coding and billing information, outlining modifiers, definitions and the associated medical policy. | May 19, 2026 |
| Malnutrition | This policy update includes updating the diagnosis criteria and professional society links | NA |
| Medical errors: serious reportable events/Hospital acquired Conditions | This policy update includes aligning with industry standard coding and billing information, outlining modifiers, definitions and the associated medical policy. | NA |
| Once per lifetime | This policy update includes additional codes for nephrectomy, abdominal aortic aneurysm, and amputations. | May 19, 2026 |
| Portable Radiology Services | This policy update indicates that Q0092 is reimbursable for each radiology procedure. | May 19, 2026 |
| OPPS status indicators | We’ve changed the name of this policy from Professional Status indicators to OPPS status indicators. There are no process changes. | NA |
| Radiology PC /TC Multiple Same-Day Billing | This policy update is for added language around modifier 76 and 77, but no actual process change. | NA |
| Readmissions Reimbursement | In this policy update, we clarify language on what will be assessed and how to report. | NA |
| Reimbursement Requirements for Outpatient Medical Drugs | Clarifying language on pharmacy | NA |
| Suction pumps | This policy updates A4624 to allow 3 units per day, and A4628 to allow 3 units per week. | NA |
| Tracheostomy supplies | To ensure accurate coding practices, documentation and billed diagnoses must substantiate the medical necessity of the item or service provided. Priority Health will comply with Centers for Medicare and Medicaid Services (CMS) guidelines, as well as relevant local coverage determinations and articles, regarding the use of diagnoses to support medical necessity. | May 19, 2026 |
| Urological Supplies | We updated the policy to add missing codes and clarify allowed quantities in the following sections:
There is no change to how providers bill. The policy now clearly outlines the allowed quantities for these codes. | May 19, 2026 |
Reminder on Rehabilitation Therapy modifiers
When billing for Rehabilitation Therapy services, the appropriate therapy modifier must be appended to all related procedure codes, as outlined in our Always / Sometimes Therapy Billing policy
Use the modifier that corresponds to the type of therapist or service rendered:
GP – Services delivered under a Physical Therapy (PT) plan of care
GO – Services delivered under an Occupational Therapy (OT) plan of care
GN – Services delivered under a Speech‑Language Pathology (SLP) plan of care
These modifiers must accompany each applicable CPT/HCPCS code to indicate the discipline responsible for the therapy service and to ensure accurate claim processing.