Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide on Oct. 1, 2024

By September 30, 2024: (1) Billing team must access and review the detailed Summary of Updates document at https://onbaseext.phs.org/PEL/DisplayDocument?ContentID=PEL_00957317 to identify specific CPT/HCPCS codes affected for each of the 18 procedures listed. (2) Update billing system workflow rules to require prior authorization checks for all affected procedures using Presbyterian's Prior Authorization Check Tool (https://prescoverage.phs.org/ac/) or myPRES Provider Portal (www.phs.org/mypres). (3) For each affected procedure, determine if prior authorization is now required or if requirements have changed; update encounter templates and billing software accordingly. (4) Train all billing staff and providers on the changes, particularly for new coverage items (lymphedema/lipedema surgical treatment) and modified requirements (e.g., pediatric bariatric surgery, TMS for Medicare/Medicaid, genetic testing categories). (5) Implement system logic to flag claims for prior authorization verification before submission for: bariatric surgery (pediatric), breast ultrasound, DME (orthotics/prosthetics, rehabilitation/mobility devices), epidural corticosteroids injections, extracorporeal photopheresis, pharmacogenomics testing (behavioral health/Medicare), all genetic/genomic testing services, hysterectomy/radiofrequency ablation (uterine fibroids), lymphedema/lipedema surgical treatment, peripheral nerve stimulation, TMS (treatment-resistant depression), and water vapor thermal therapy (Rezūm system). Failure to obtain required prior authorizations will result in claim denials. Contact Presbyterian Provider Network Operations at (505) 923-5757 or 1-888-923-5757 (Monday-Friday, 8am-5pm) with questions.