What types of policy changes does Presbyterian Health Plan issue?

Presbyterian Health Plan regularly publishes coverage updates including prior authorization requirement changes, billing code additions or deletions, plan-type coverage modifications, and clinical policy revisions. PolicyChanges.app monitors these notices and summarizes the impact for providers.

How often does Presbyterian Health Plan update its policies?

Presbyterian Health Plan typically releases policy bulletins on a rolling basis throughout the year. Our system checks for new updates daily and adds them to this feed as soon as they are identified.

How many Presbyterian Health Plan policy changes are tracked here?

This page currently tracks 14 documented Presbyterian Health Plan policy changes. New items are added as they are identified.

What should I do when Presbyterian Health Plan changes a prior authorization policy?

Review each change's effective date and action-required notes. Update your billing and clinical workflows before the effective date to avoid claim denials. Each policy detail page on PolicyChanges.app includes a plain-English summary and action items.

Presbyterian Health Plan Policy Changes & Prior Auth Updates

We track 14 documented policy changes from Presbyterian Health Plan across NM. Each entry includes an AI-generated plain-English summary, effective date, affected billing codes, and a direct link to the original Presbyterian Health Plan notice. Use the related links below to narrow results by specialty or state, or sign up for a free daily alert to receive new Presbyterian Health Plan updates automatically.

High impact
2026 March Network Connection
Presbyterian Health Plan·Effective Mar 13, 2026
Presbyterian is implementing Turquoise Claims, a new New Mexico Medicaid claims submission system going live March 23, 2026. Starting March 13, 2026, Presbyterian will stop creating secondary claims for dual-coverage members, requiring providers to submit both primary and secondary claims directly. Providers must use specific identifiers (Payor ID 77048, Loop 2010BB NMPHP) and verify member information against the HCA portal to ensure accurate claim payment.
High impact
2026 January Network Connection
Presbyterian Health Plan·Effective Jan 1, 2026
Presbyterian Health Plan released its 2026 provider manuals and announced several operational changes effective January 1, 2026, including the removal of all CVS Pharmacy locations from the Medicare network, requiring patients to transfer prescriptions to in-network pharmacies. The policy also establishes mandatory well-child visit requirements within 30 days for children entering state custody (CISC) covered under Turquoise Care, with specific coding and reimbursement guidance for providers.
High impact
Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide on Oct. 1, 2025
Presbyterian Health Plan·Effective Oct 1, 2025
Presbyterian Health Plan is updating its Medical Policy Manual and Prior Authorization Guide effective October 1, 2025, adding and/or modifying prior authorization requirements for 12 procedures including bariatric surgery for pediatric patients, durable medical equipment, genetic testing, epidural injections, and hemodialysis access procedures. Billing teams must verify which procedures now require prior authorization and update workflows accordingly.
High impact
Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide July 1, 2025
Presbyterian Health Plan·Effective Jul 1, 2025
Presbyterian Health Plan is updating its Medical Policy Manual and Prior Authorization Guide effective July 1, 2025. The update includes new coverage policies for gender-affirming treatment/surgery, genetic testing (multiple types), gastric electric stimulation, peripheral nerve stimulation, and home health care; removes coverage for 10 previously covered services (including bone marrow transplants, organ transplants, sacral nerve stimulation, and others); and modifies requirements for durable medical equipment and rehabilitation devices. Billing teams must verify prior authorization requirements for all affected procedures using Presbyterian's updated tools.
High impact
Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide April 1, 2025
Presbyterian Health Plan·Effective Apr 1, 2025
Presbyterian Health Plan is updating its Medical Policy Manual and Prior Authorization Guide effective April 1, 2025, retiring 10 procedures from prior authorization requirements while adding or modifying coverage policies for 10 other services including gender affirming treatment, DME categories, cancer clinical trials, TMS, and organ transplants. Billing teams must immediately review the detailed Summary of Updates document to identify which procedures no longer require prior auth and which newly require it, then update their authorization workflows and billing system rules accordingly.
High impact
2025 January Network Connection
Presbyterian Health Plan·Effective Jan 1, 2025
Effective January 1, 2025, Stanson Health replaces Evolent/NIA for advanced imaging authorizations in non-emergency outpatient settings. Providers must now obtain prior authorization from Stanson for advanced diagnostic imaging studies. Evolent/NIA continues for spinal surgery authorizations only. Optum remains the authorizing entity for Presbyterian Medicare Advantage members assigned to Optum-employed PCPs.
Medium impact
2025 September Network Connection
Presbyterian Health Plan·Effective Sep 1, 2025
Presbyterian has expanded breast cancer screening HEDIS measures effective immediately for Measurement Year 2025, lowering the recommended screening age from 50 to 40 years old and stratifying reporting by age groups (40-49 and 50-74). Providers should now recommend screening mammograms starting at age 40 for women at average risk. Additionally, Presbyterian is expanding its ophthalmology network in Q4 2025 and introducing new wellness programs, perinatal food benefits, and provider education requirements.
Medium impact
2025 July Network Connection
Presbyterian Health Plan·Effective Aug 1, 2025
Presbyterian is transitioning its mail-order prescription service from Optum Home Delivery to Costco Pharmacy effective August 1, 2025, for non-specialty medications only. Members must enroll with Costco Pharmacy to continue receiving mail-order prescriptions, and no Costco membership is required. Providers can begin sending prescriptions to Costco Pharmacy Mail Order immediately via electronic or fax submission.
Medium impact
2025 May Network Connection
Presbyterian Health Plan·Effective May 1, 2025
Presbyterian is expanding preventive care services through home-based testing kits (HbA1c/kidney function tests for diabetic patients and Cologuard for colorectal cancer screening in adults 45+), implementing new maternity telehealth partnerships via Ouma Health, and promoting virtual dermatology visits. The policy also highlights documentation improvement areas from 2024 medical record audits, particularly for advance directives, immunizations, and asthma triggers. Billing teams should monitor for new telehealth service codes and ensure proper documentation to support these preventive initiatives.
Medium impact
2025 March Network Connection
Presbyterian Health Plan·Effective Mar 1, 2025
Presbyterian is implementing a health equity initiative requiring providers to update demographic information (race, ethnicity, languages spoken, cultural training) in the online provider directory and PROVIDERConnect Portal. Providers must complete cultural competency training and ensure directory information is current to meet regulatory compliance under the Consolidated Appropriations Act. Multiple mandatory training events are scheduled throughout 2025.
Medium impact
2026 May Network Connection
Presbyterian Health Plan·Identified May 1, 2026
Presbyterian's May 2026 Network Connection newsletter emphasizes quality improvement initiatives and compliance requirements for contracted providers. Key updates include: (1) Kidney Health Evaluation (KED) HEDIS measure promoting annual eGFR and uACR testing for diabetic patients to improve early chronic kidney disease detection; (2) Results from 2025 medical record audits showing 97.8% overall compliance but highlighting deficiencies in advance directive documentation (27.2%) and immunization records; (3) Mandatory 90-day provider directory verification deadline of June 30, 2026; and (4) Multiple provider education and training requirements throughout 2026.
Medium impact
2025 November Network Connection
Presbyterian Health Plan·Identified Nov 1, 2025
This November 2025 Presbyterian Network Connection is a multi-topic provider newsletter covering quality measure compliance (blood pressure control), required provider education events, wellness program resources, claims submission best practices, and Medicare Star Ratings guidance. Key billing-relevant items include reminders to document compliant blood pressure readings for HEDIS measures, proper electronic claims submission procedures, and upcoming changes to blood pressure quality measures. No immediate billing code or reimbursement changes are mandated.
Medium impact
2024 September Network Connection
Presbyterian Health Plan·Identified Sep 1, 2024
Presbyterian's September 2024 Network Connection newsletter contains a regulatory update to CPT code +99417 (prolonged E/M services). The revision clarifies that the 15-minute initial time unit for +99417 can only be added once the primary E/M code's time threshold is exceeded by 15 minutes, and +99417 should not be reported for any time unit less than 15 minutes. This affects how providers bill for prolonged office visits and consultations.
Low impact
2024 November Network Connection
Presbyterian Health Plan·Identified Nov 1, 2024
This is a Presbyterian November 2024 provider newsletter containing multiple informational updates and program announcements, including CAHPS survey preparation guidance, wellness program referral pathways, opioid use disorder pharmacotherapy treatment standards (180-day minimum), cybersecurity scam alerts, and preventive health resources. No billing code changes, coverage modifications, or prior authorization requirement changes are implemented.

Presbyterian Health Plan in NM Presbyterian Health Plan: Bariatric Surgery Presbyterian Health Plan: Cardiology Presbyterian Health Plan: Dermatology Presbyterian Health Plan: Endocrinology All payers

Get alerts for changes like this

Save a search and receive a daily digest whenever a new policy change matches your filters.

Create a free alert

Presbyterian Health Plan Policy Changes 2026 | Prior Auth & Coverage Updates | PolicyChanges.app

2026 March Network Connection

2026 January Network Connection

Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide on Oct. 1, 2025

Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide July 1, 2025

Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide April 1, 2025

2025 January Network Connection

2025 September Network Connection

2025 July Network Connection

2025 May Network Connection

2025 March Network Connection

2026 May Network Connection

2025 November Network Connection

2024 September Network Connection

2024 November Network Connection