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 | ||
| Osteopathic Manipulation Treatment (OMT) (#200) | These new policies provide industry-standard coding and billing information, outlining modifiers, definitions and associated medical policies. | Sept. 23, 2026 |
| Split Billing (#201) | ||
| Trauma Team Activation (#202) | ||
| Updated policies | ||
| Bowel Management Devices (#150) | We’ve revised some language for clarity and removed effective dates for HCPCS codes A4459 and A4453, as both codes are currently effective. We’ve also added a CPT code reference chart under the Coding Guidelines section. | Jul. 23, 2026 |
| Cervical Traction Devices (#109) | We’ve added a reference link to the Durable Medical Equipment (DME) Capped Rental Policy (Policy 110) and included guidance on the appropriate use of modifier RR. | |
| Inpatient Only Procedures (#014) | We’ve added language regarding InterQual criteria and the applicable medical policy to clarify review requirements and coverage determination guidelines. | |
| Modifier 25 | We’ve updated information on providers in the same practice billing new versus established patients, in alignment with requirements from the AMA and CMS. | |
| Positive Airway Pressure (PAP) Devices For Treatment of Obstructive Sleep Apnea (#020) | We’ve added clarification that supply limits are calculated on a rolling calendar basis. | |
| Pulmonary Function Testing (#136) | We’ve added definitions for the various pulmonary function tests (PFTs) to enhance clarity. | |
| Radiation Oncology (#027) | We’ve added supplemental guidance to support denial rationale, including clarification that one unit of CPT® 77338 is reimbursable per eight-week period. We’ve also incorporated image fusion billing guidance under the Dosimetry section. | |
| Reimbursement Requirements for Outpatient Medical Drugs (#092) | We’ve removed code J9271 from the Examples section, as it’s no longer included in the edit criteria. | |
| Sacroiliac Joint Injections & Procedures (#114) | We’ve corrected any errors in billing codes. | |
| Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (#030) | We’ve added standardized code definitions to improve consistency and incorporated SCODI testing information to support coding and coverage guidance. | |
| Therapeutic Shoes Diabetic (#163) | We’ve added the associated medical policy and updated the language to direct providers to the medical policy for frequency guidelines and limitations. | |
| Transcutaneous Electrical Joint Stimulation Devices (#116) | We’ve updated the Definitions section. | |
| Chelation Therapy (#159) | We’ve added guidance directing providers to Medical Policy 91077: Chelation Therapy, for applicable medical necessity criteria and qualifying diagnoses. | Sept. 23, 2026 |
| Non-invasive Peripheral Arterial Vascular Studies/ Non-Invasive Peripheral venous vascular & Hemodialysis Studies (#097) | We’ve added language clarifying that Priority Health follows CMS-established diagnostic criteria for noninvasive peripheral arterial vascular studies when determining medical necessity and coverage. | Sept. 23, 2026 |