Q2 2026 Provider Newsletter

REQUIREMENTS: By June 1, 2026: Billing team must implement system updates to identify and recoup non-exact duplicate inpatient hospital claims where the same member, provider, and hospital have overlapping dates of service billed under different DRGs or Types of Bill. Update claim processing workflows to apply denial code 'h2' with provider letter stating 'The member was ineligible for coverage on the date of service. An overpayment of $XX will be recouped.' Coordinate with compliance to ensure accurate identification before recoupment. Before August 1, 2026: Billing team must verify that billing software restricts reimbursement of CPT codes S9083 (global fee urgent care centers) and S9088 (urgent care add-on code) ONLY when billed with place of service 20 (urgent care facilities). All claims submitted with any other place of service must be automatically denied. Update encounter forms and provider communications to specify that these codes are not reimbursable in other settings. Train billing staff to validate place of service before claim submission. By July 1, 2026: Billing team must implement national CPT billing guidelines for outpatient emergency department E&M code leveling per policy CC.PP.80. Update coding rules to apply facility resource-based E&M level determination (nursing time, clinical staff effort, supplies, equipment, overhead) rather than physician cognitive work. Implement recoding logic to adjust E&M codes to the highest service level for which criteria is satisfied based on comparative peer risk adjustment process. Configure system to apply EXLc AMISYS code for tracking. Notify providers and ED coding staff of the shift from provider-based to facility resource-based E&M coding standards. Immediately: Billing team must register for and complete CDI 2026 Webinar Series on Risk Adjustment, Coding, and Documentation Education. Ensure at least one representative from billing, coding, and provider support attends. Email CDIWebinars@centene.com for registration assistance. Disseminate webinar materials to entire billing department. Consequences of inaction: Failure to implement these changes will result in claim denials, recoupment notices, payment accuracy violations flagged by CMS/OIG, and potential compliance issues with HHS audit requirements for RADV compliance.