Clinical and Payment Policy Updates, Effective 10/9/2026 (PDF)

By October 9, 2026: (1) Billing team must review all 10 new infectious disease lab testing policies (CG.CP.MP.01 through CG.CP.MP.07) and map applicable CPT/HCPCS codes used in your practice to the new medical necessity criteria. (2) For genetic testing claims: Update billing system to recognize that procedure code description (recommended to use GTU) is required for non-specific codes 81479, 81599, and Tier 2 codes per policy CG.PP.551C; labs do not need to register with Concert but claims will be edited based on these requirements. (3) For skin substitute graft claims (CP.MP.185): Implement requirement that providers document wound care specialist involvement and confirmation that underlying conditions are being treated; update authorization workflows to verify specialist management before approving claims. (4) For genitourinary diagnostic testing (CP.MP.97): Review vaginitis diagnostic protocols and ensure billing reflects appropriate test selection per medical necessity criteria. (5) For new Relizorb immobilized lipase cartridge claims (CP.MP.252): Establish prior authorization workflow for Medicaid/Marketplace members requiring medical necessity documentation. (6) Clinical staff should communicate updated policy language to all providers, particularly regarding Concert genetic testing (change from "investigational" to "current evidence does not support") to ensure accurate medical record documentation. Failure to comply with medical necessity criteria will result in claim denials and potential recoupment.