May 2023 code edit implementation update
Our code edit implementation has been delayed by a few weeks. Also, the lab-panel billing change will not be included in the implementation. In light of the feedback from our network lab facilities, we are re-evaluating our approach on this and will be in touch if there will be any future changes.

Vaccine code edit correction has been implemented
We have updated our system for CPT^® codes 90707 (MMR vaccine) and 90716 (varicella vaccine) so that they will both be reimbursed appropriately. Starting January 1, 2023, the codes were inadvertently configured to deny when billed together. Affected claims will be reprocessed to correct this error.

Revised prior auth code list now available
The prior authorization code list and lookup tool have been updated to indicate the additional drugs that now require a site-of-service review (effective May 1). See the article in last month’s edition for more information.

End of COVID-19 public health emergency
Pre-pandemic review processes and requirements have resumed. For details, see the notes in the updated table of emergency measures.

PCP referral approvals are not required at this time
For PCP-HMO plans, we’re still waiving the PCP referral approval requirement until further notice. Please continue to make in-network referrals for specialist office visits. We will let you know when approval for such referrals is once again required.