Medicare AdvantagePrior AuthHigh impact
Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide on May 1, 2024
Presbyterian Health Plan·NM · Dermatology, General Surgery, Plastic Surgery +8 more·Prior Authorization
Effective date
May 1, 2024
We identified it
May 1, 2024
Summary
Presbyterian Health Plan is updating its Medical Policy Manual and Prior Authorization Guide effective May 1, 2024, adding and/or modifying prior authorization requirements for 24 procedures and services. This includes two new commercial policies (Clinical Trials Routine Patient Care Costs and Specialized Specimen Procedures) and updates to existing policies across multiple clinical areas. Billing teams must review the detailed updates document and adjust prior authorization workflows accordingly.
Action Required
By April 30, 2024: Billing team must access the detailed Summary of Updates document at https://onbaseext.phs.org/PEL/DisplayDocument?ContentID=PEL_00957317 to identify specific CPT/HCPCS codes affected by each policy modification. Update billing software, encounter templates, and prior authorization workflows to reflect the new requirements for all 24 procedures listed (including: tissue-engineered skin substitutes, autism spectrum disorder treatment, breast surgery, capsule endoscopy, DME categories, genetic testing, sleep studies, tonsillectomy, vagus nerve stimulation, and others). For the two new commercial policies, configure the billing system to route claims to prior authorization verification using the Prior Authorization Check Tool (https://prescoverage.phs.org/ac/) or myPRES portal before claim submission. Train clinical and administrative staff on the changes. Document changes in internal billing procedures. Verify prior authorization requirements using the Medical Policy Manual (www.phs.org/providers/resources/medical-policy-manual) and Prior Authorization Guide (www.phs.org/providers/authorizations). Failure to obtain required prior authorizations will result in claim denials.