All PlansBilling CodesMedium impact
August 2026 billing policy updates
Priority Health·Cardiology, General Surgery, Ophthalmology +2 more·Claims & Billing
Effective date
Aug 20, 2026
We identified it
Aug 18, 2026
Summary
Priority Health published August 2026 billing policy updates affecting multiple service areas including cardiovascular disease risk assessment, cervical fusion, DME rental, H. pylori testing, nerve blocks, and ophthalmic imaging. Key changes include code additions/removals, modifier updates, CMS alignment language for medical necessity criteria, and policy link corrections. Three new policies effective October 20, 2026 address charge master coding, nutrition counseling, and robotic-assisted surgery.
Action Required
By August 20, 2026: Billing team must implement the following changes in Priority Health claims processing and billing software: (1) Add CPT code G0537 to cardiovascular disease risk assessment billing rules and remove any non-covered screening diagnosis codes per policy #132; (2) Update DME capped rental processing to recognize modifier BP and revise KJ modifier definitions per policy #110; (3) Add H. pylori testing medical policy link to reference documentation per policy #151; (4) Update nerve blocks for peripheral nerve neuropathy claims to align with CMS medical necessity criteria per policy #146; (5) Update SCODI ophthalmic imaging claims to align with CMS medical necessity criteria per policy #030. For policies effective October 20, 2026: before that date, ensure systems are ready to process new charge master coding (policy #206), nutrition counseling/education/therapy codes (policy #204), and robotically assisted surgery codes (policy #205). Verify cervical fusion policy #148 links and CPT codes are current in EMR and billing templates. Failure to implement these changes may result in claim denials and processing delays.