All PlansBilling CodesHigh impact
Sept. 2026 billing policy updates
Priority Health·Endocrinology, Gastroenterology, General Practice +1 more·Claims & Billing
We identified it
Sep 15, 2026
Summary
Priority Health issued 11 billing policy updates effective immediately and two policies with delayed implementation on Nov 16, 2026. Key changes include: (1) new CGM billing code requirements with denials for non-compliant codes, (2) removal of medical necessity criteria and frequency limits for certain procedures, (3) clarifications on provider-based billing and included supplies, and (4) updated colorectal cancer screening guidance. Billing teams must immediately implement software changes for CGM codes and provider-based billing rules, with additional updates required before November 16, 2026.
Action Required
IMMEDIATE ACTIONS (Effective Now): (1) Billing team must update billing software to REQUIRE HCPCS codes A4238 and A4239 for all continuous glucose monitoring (CGM) equipment and supplies. (2) Configure system to DENY claims containing HCPCS codes A9276, A9277, and A9278 for CGM services with automated rejection messages. (3) Update claim scrubbing rules to flag Z41.8 as cosmetic codes that require review rather than automatic denial. (4) Revise provider-based billing rules to mark routine supplies and commonly packaged drugs/biologicals as inclusive to professional charges—these should NOT be billed separately on facility claims. BEFORE NOVEMBER 16, 2026: (1) Implement system changes for provider-based billing to prevent billing of specific revenue codes with clinic/provider-based services. (2) Update clinical edits to reflect removal of medical necessity criteria for Blood Counts (#184) and Facet Joint Interventions (#142). (3) Train billing and coding staff on updated Colorectal Cancer Screening policy changes (age/frequency requirements for Cologuard Plus, authorization language removals). (4) Ensure prior authorization workflows reflect new language for Cologuard and Shield screening tests. CONSEQUENCES: Claims billed with CGM codes A9276, A9277, A9278 will be denied. Claims with inappropriately billed routine supplies on facility claims will be rejected. Non-compliant provider-based billing claims will incur delays and rebilling.