Medicare AdvantageCoverageHigh impact
MA00.010au, PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Independence Blue Cross·Physical Therapy, Radiology, PM&R (Physical Medicine & Rehab)·Network
Effective date
Oct 1, 2025
We identified it
Jun 19, 2026
Summary
This policy establishes PPO Network Rules for specialty services including Durable Medical Equipment (DME), Laboratory, Radiology, and Physical Medicine & Rehabilitative Services for Medicare Advantage plans effective 10/01/2025. The billing team must review the full policy text to identify specific network requirements, prior authorization mandates, and in-network vs. out-of-network billing rules that may affect claims processing for these service categories.
Action Required
By 10/01/2025: Billing team must obtain and review the complete MA00.010au policy from the source URL to identify: (1) which DME, laboratory, radiology, and PM&R services require prior authorization, (2) in-network vs. out-of-network facility requirements, (3) any billing code restrictions or limitations. Update billing software, encounter forms, and provider order entry systems with new network rules. Verify all claims for these service categories are submitted to correct in-network facilities per new PPO rules. Flag non-compliant claims for reprocessing. Communicate requirements to providers and DME/lab/radiology vendors. Failure to comply will result in claim denials or payment reductions for out-of-network services.