Prior Authorization Tool Maintenance

IMMEDIATE ACTIONS REQUIRED (Multiple Deadlines): 1. By June 26, 2026 at 6:00 PM: Billing team must establish backup process for urgent prior authorization requests during system maintenance (June 26-29, 2026). Prepare State of Vermont Uniform Medical Prior Authorization Form templates and ensure fax capability to (866) 387-7914. All routine PA requests must be submitted before 6:00 PM on June 26. 2. By July 3, 2026: Billing team must update claims system to require National Drug Code (NDC), Unit of Measure (UoM), and Quantity fields for applicable services identified in the full list. Review current claim submissions for these service lines and update templates. Service lines missing NDC, UoM, and Quantity will be denied effective July 3, 2026. 3. By August 1, 2026: Providers and billing staff must review and implement two new Medical Nutrition Therapy policies (Medical Nutrition Therapy and Nutritional Counseling Medical Policy AND Payment Policy). Archive outdated Nutritional Counseling Medical Policy. Update prior authorization requirements and billing procedures accordingly. Review current patient cases for impact. 4. By September 1, 2026: Ensure CAA Provider Directory Validation for Q3 (due by approximately August 4, 2026 based on July 4 release date) is completed within 30-day window. Billing team must monitor validation status. Non-compliant providers will have claims denied under non-confirmed NPI starting September 1, 2026. Denied claims must be resubmitted after validation completion. 5. By September 19, 2026: Radiology staff and billing team must review updated Carelon Clinical Practice Guidelines for Radiology Services. Update medical necessity documentation requirements and prior authorization criteria for radiology services provided on or after September 19, 2026. 6. By January 1, 2027: Providers and billing team must stop billing the global maternity care code effective December 31, 2026. Replace with new CPT codes mandated by AMA. Update EMR templates, encounter forms, and billing system rules. Claims submitted with global code on or after January 1, 2027 will be denied. 7. Effective October 1, 2026: Billing team and practice management must enroll in Electronic Fund Transfer (EFT) payments through PayeeHub before this date. Contact (877) 882-0384 to enroll. Paper checks will no longer be issued. Ensure Provider Resource Center (PRC) enrollment is active to receive ERA/835 vouchers going forward.