All PlansPrior AuthHigh impact
Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide on Oct. 1, 2025
Presbyterian Health Plan·NM · Bariatric Surgery, Pediatrics, Orthopedics +6 more·Prior Authorization
Effective date
Oct 1, 2025
We identified it
Oct 1, 2025
Summary
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.
Action Required
By September 30, 2025: (1) Billing team must access the detailed policy updates at https://onbaseext.phs.org/PEL/DisplayDocument?ContentID=PEL_00957317 to identify specific CPT/HCPCS codes affected by the 12 modified procedures (MPM 40.0, 4.2, 4.6, 5.9, 5.7, 7.13, 7.7, 29.0, 7.12, 36.0, 30.0, 55.0). (2) Update billing software rules and encounter forms to require prior authorization for all affected procedures per the updated Presbyterian Prior Authorization Guide. (3) Train front desk and clinical staff on new prior auth requirements. (4) Providers should use myPRES portal (www.phs.org/mypres) and the Prior Authorization Check Tool (https://prescoverage.phs.org/ac/) to verify authorization requirements before submitting claims. Failure to obtain required prior authorization will result in claim denials. Contact Presbyterian Provider Network Operations at (505) 923-5757 or 1-888-923-5757 with implementation questions.