All PlansPrior AuthHigh impact
Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide April 1, 2025
Presbyterian Health Plan·NM · Cardiology, Neurology, Sleep Medicine +8 more·Prior Authorization
Effective date
Apr 1, 2025
We identified it
Apr 1, 2025
Summary
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.
Action Required
REQUIREMENTS:
- By March 31, 2025: Billing team and prior authorization staff must access and review the complete Summary of Updates at https://onbaseext.phs.org/PEL/DisplayDocument?ContentID=PEL_00957317 to identify specific CPT/HCPCS codes affected by each retired or modified procedure.
- Before April 1, 2025: Update billing system rules and prior authorization decision trees to remove prior auth requirements for the 10 retired procedures: Breast Ultrasound, Cholecystectomy, Extracorporeal Shock Wave Therapy (ESWT), Implantable Cardioverter Defibrillator (ICD), Minimally Invasive Lumbar Decompression (mild/PILD), Percutaneous Coronary Interventions, Plasma Exchange/Therapeutic Apheresis, Transcranial Magnetic Stimulation (TMS) for Commercial, and Water Vapor Thermal Therapy (REZum).
- Before April 1, 2025: Update billing system rules to ADD prior authorization requirements (if not already present) for modified/new policies: Cancer Clinical Trials Routine Patient Care Costs (Medicaid), Durable Medical Equipment (Miscellaneous, Respiratory Devices, Orthotics/Prosthetics, PAP/Oral Appliances for Sleep Apnea), Gender Affirming Treatment and Surgery (Adults 18+), Gender Affirming Treatment (Children/Adolescents 17 and under), Outpatient In-Facility Observation, Restorative/Reconstructive/Cosmetic Surgery, Transcranial Magnetic Stimulation (TMS) for Treatment-Resistant Depression (all plans except Commercial), and Organ Transplants.
- Update front-end encounter forms and EMR templates to reflect new/retired prior authorization requirements.
- Train billing staff and providers on which services now bypass prior authorization and which newly require it to prevent incorrect claim submissions and denials.
- Failure to implement these changes by April 1, 2025 will result in claims being improperly denied or approved without required authorization, creating revenue cycle problems and compliance issues with Presbyterian.