Drug dosing modifier (JW/JZ) edit denying in error
Key Update Claims billed in accordance with the Priority Health Provider Manual (JW/JZ modifier guidance)—with no modifier on line 1—are currently denying inappropriately.
Reminder: medical documentation required for billing above MUE limits
When services are billed above the Medically Unlikely Edit (MUE) limit, we require clear, specific medical documentation to support the additional units. Without this detail, claims may be reduced or denied — even when care is clinically appropriate. Documentation must explain why additional units were medically necessary for that specific date of service.
Reminder: new payment & RA processes coming Sept. 1
On Sept. 1, 2026*, you’ll start receiving claim and capitation payments, remittance details and 1099s from ECHO Health Inc., in partnership with Optum Financial.
05/16/2026: May 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.
Start using E/M codes for maternity services billing in June
The American Medical Association (AMA) recently announced new obstetric (OB) CPT codes that will replace the bundled, global OB payment for maternity care services, effective Jan. 1, 2027. We encourage providers caring for pregnant women to start using existing E/M codes when billing for patients starting their prenatal visits on / around June 1, 2026.
04/16/2026: April 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.
Optum payments update: EFT data transfer, payment options overview and more
As we prepare to offer our provider network more payment options by working with Optum Financial (Optum) and ECHO Health Inc (ECHO), we want to make sure everyone understands the available payment options and any actions providers may need to take.
03/16/2026: March 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.
Update: EOBs no longer accepted through prism inquiries for claim reprocessing
Effective May 5, 2026 we'll no longer accept an EOB attached to a prism inquiry for claim adjustment. If a claim is denied for needing the other payer’s information, providers must resubmit the claim electronically with the other insurance payment information included.
02/11/2026: February 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.
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.
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.