All PlansPrior AuthHigh impact
Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide on Nov. 1, 2024
Presbyterian Health Plan·NM · Pain Management, Bariatric Surgery, Dermatology +5 more·Prior Authorization
Effective date
Nov 1, 2024
We identified it
Nov 1, 2024
Summary
Presbyterian Health Plan is updating its Medical Policy Manual and Prior Authorization Guide effective November 1, 2024, adding new procedures, modifying existing ones, and retiring three procedures (Autologous Chondrocyte Implantation, Meniscal Allograft Transplant, Thoracic Spinal Surgeries, and Unicompartmental Knee Replacement). Billing teams must verify prior authorization requirements for all affected procedures using Presbyterian's updated resources and tools.
Action Required
By October 31, 2024: (1) Billing team must review the full Summary of Updates document at https://onbaseext.phs.org/PEL/DisplayDocument?ContentID=PEL_00957317 to identify specific prior authorization requirement changes for each procedure. (2) Update internal prior authorization workflows and billing system rules to reflect the 14 modified/retired procedures listed. (3) Immediately STOP requesting prior authorizations for the four retired procedures (Autologous Chondrocyte Implantation, Meniscal Allograft Transplant, Thoracic Spinal Surgeries, Unicompartmental Knee Replacement) to prevent unnecessary claim delays. (4) Verify the new acupuncture, bariatric surgery, genetic testing, and radiation oncology requirements using the Prior Authorization Check Tool (https://prescoverage.phs.org/ac/) and Medical Policy Manual (www.phs.org/providers/resources/medical-policy-manual). (5) Update encounter forms and clinical documentation templates to reflect new prior authorization triggers. (6) Train all providers and front desk staff on the changes. Failure to obtain required prior authorizations will result in claim denials; submitting prior auth for retired procedures may delay processing.