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.
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.
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.
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:
11/01/2025: 2026 commercial fee schedules are available online
2026 commercial fee schedules are available online
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.
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:
10/13/2025: October 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.
9/25/2025 Provider news: Reprocessing incorrectly rejected Medicaid claims
We recently experienced an issue with some Medicaid claims containing drug-related lines being front-end rejected for “Missing/Invalid NDC” when they shouldn’t.
09/15/2025: September 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.
9/4/2025: Reprocessing claims incorrectly rejected for Medicaid edit 1462
We recently experienced a brief issue with some Medicaid claims being front-end rejected for “Missing/Invalid NDC” when they shouldn’t.
August 2025 billing policy updates
The following billing policies were recently published to or updated in our Provider Manual’s Billing Policies page.