Medicare AdvantagePrior AuthHigh impact
Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide July 1, 2025
Presbyterian Health Plan·NM · General Surgery, OB-GYN, Urology +10 more·Prior Authorization
Effective date
Jul 1, 2025
We identified it
Jul 1, 2025
Summary
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.
Action Required
By June 30, 2025: Billing team must complete the following: (1) Access Presbyterian's Prior Authorization Guide & Medical Policy Manual Summary of Updates at https://onbaseext.phs.org/PEL/DisplayDocument?ContentID=PEL_00957317 to identify specific billing codes affected by each policy change; (2) Update billing system rules to reflect NEW prior authorization requirements for gender-affirming treatment/surgery, gastric electric stimulation, peripheral nerve stimulation, genetic/biomarker/genomic testing (all types), and home health care; (3) REMOVE prior authorization workflows or coverage for the 10 retired procedures (bone marrow transplants, organ transplants, sacral nerve stimulation, photodynamic therapy for ocular conditions, platelet-rich plasma for wounds, prophylactic surgery, prostate BPH surgery, and others); (4) Update encounter templates and claim scrubbing logic to reflect coverage changes; (5) Train providers on new prior authorization requirements using the myPRES Provider Portal and Prior Authorization Check Tool (https://prescoverage.phs.org/ac/). Contact Provider Network Operations at (505) 923-5757 or 1-888-923-5757 for specific code mappings. Failure to obtain prior authorization where required will result in claim denials; claims for retired procedures will be denied as non-covered services.