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Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide on Oct. 1, 2024
Act
by Sep 30, 2024
Effective date
Oct 1, 2024
Identified
Oct 1, 2024
Summary
Presbyterian Health Plan is updating its Medical Policy Manual and Prior Authorization Guide effective October 1, 2024, adding and modifying prior authorization requirements for 18 procedures/services including new coverage for lymphedema and lipedema surgical treatment, bariatric surgery for pediatric patients, genetic/genomic testing, and various other procedures. Billing teams must verify prior authorization requirements for all affected procedures using Presbyterian's online tools before claims submission.
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What to do
by Sep 30, 2024 · 7 steps
01Billing 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.
02Update 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).
03For each affected procedure, determine if prior authorization is now required or if requirements have changed; update encounter templates and billing software accordingly.
04Train 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).
05Implement 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).
06Failure to obtain required prior authorizations will result in claim denials.
07Contact Presbyterian Provider Network Operations at (505) 923-5757 or 1-888-923-5757 (Monday-Friday, 8am-5pm) with questions.
Original notice
Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide on Oct. 1, 2024
onbaseext.phs.org · Always check the source before changing claims.
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