We publish billing policies to offer transparency and help you bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.
The following billing policies were recently published to or updated in our Provider Manual’s Billing Policies page.
Note: If the effective date is listed as N/A, the policy represents our current system set up and/or expectations for transparency. There are either no changes for you as the policy is already in effect or was recently shared with the network and we’re implementing a clinical edit in alignment with the policy’s language.
| Billing policy | New or updated | Description | Effective date |
| Add-on codes (#90) | Updated | Added "Related denial language" section with a prism denial code (pf9) that applies to claims effective July 8, 2025. | N/A |
| Ambulatory surgical centers (#088) | Updated |
| Sept. 22, 2025 |
| Anesthesia (#107) | Updated |
| N/A |
| Autonomic function testing (#115) | New | This policy identifies the payment and documentation requirements associated with autonomic function testing, a series of non-invasive procedures that access the function of the autonomic nervous system. | N/A |
| Capsule endoscopy (#112) | New | This policy identifies the payment and documentation requirements associated with capsule endoscopy, noninvasive, sedation-free procedures that use a small, swallowable capsule with a built-in camera to capture images of the colon. | N/A |
| Cervical traction devices (#109) | New | This policy identifies the payment and documentation requirements associated with cervical traction devices, used to gently stretch the neck to relive pain and reduce pressure on the cervical spine. | N/A |
| Durable medical equipment (DME) capped rental (#110) | New | This policy outlines billing requirements for DME capped rentals. | N/A |
| Durable medical equipment (DME) repair and replacement (#108) | New | This policy identifies the payment and documentation requirements associated with various durable medical equipment (DME) supplies. | N/A |
| Evaluation and management (#010) | Updated |
| N/A |
| Foot care and onychomycosis testing (#113) | New | This policy identifies the payment and documentation requirements associated with routine foot care and onychomycosis (mycotic nails) testing. | N/A |
| Genetic testing, counseling and screening (#011) | Updated |
| N/A |
| High-level E/M with preventive exam (#111) | New | This policy outlines guidelines for reporting high level evaluation and management codes (99204/99205 and 99214/99215) on the same day as a preventive medicine service (99385, 99386, 99387, 99395, 99396, 99397) by the same provider for a member. | Sept. 22, 2025 |
| Miscellaneous durable medical equipment (DME) (#017) | Updated |
| Sept. 22, 2025 |
| Polysomnography and sleep studies (#118) | New | This policy identifies the payment and documentation requirements associated with polysomnography and sleep studies, diagnostic tests utilized to diagnosis sleep disorders such as sleep apnea, narcolepsy, hypersomnia. | N/A |
| Sacroiliac joint injections and procedures (#114) | New | This policy identifies the payment and documentation requirements associated with sacroiliac joint injection, a medical procedure where a needle is used to inject a combination of the anesthetic and steroid medication into the sacroiliac joint, which is connects the spine to the pelvis. | N/A |
| Transcutaneous electrical joint stimulation devices (#116) | New | This policy addresses the use of transcutaneous electrical nerve stimulation (TENS) devices to treat pain. | N/A |
| Upper limb stimulation for the treatment of tremors (#117) | New | This policy identifies the payment and documentation requirements associated with upper limb stimulation for the treatment of tremors. | N/A |