Navigate Shifting Reimbursement Criteria for Molecular Testing
At TELCOR, we’ve recently identified a notable shift in how molecular claims specifically associated with CPT code 87798, are being processed by...
1 min read
The national trade association America’s Health Insurance Plans (AHIP) announced on June 23 that major U.S. health insurers are committing to take a series of action to simplify and improve prior authorization.
“The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike. Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care, while also helping to modernize the system,” said AHIP President and CEO Mike Tuffin in a press release.
The participating health plans committed to the following provisions:
- Implementation of standardized electronic prior authorization, including the development of standardized data and submission requirements. The goal is to have an operational framework available to plans and providers by Jan. 1, 2027.
- Reduction in the scope of claims subject to prior authorization, with demonstrated reductions made by Jan. 1, 2026.
- Retention of existing prior authorizations for benefit-equivalent in-network services as part of a 90-day transition period when a patient changes insurance companies during a course of treatment, beginning Jan. 1, 2026.
- Provision of clear explanations for prior authorization determinations, with guidance on appeals and next steps, to be operational for fully insured and commercial coverage by Jan. 1, 2026.
- Expansion of real-time responses for at least 80 percent of electronic prior authorization approvals with all necessary clinical documentation, by 2027.
- Continuation of an existing standard for all nonapproved requests based on clinical reasons to be reviewed by medical professionals.
All provisions of the pledge will be implemented across insurance markets to include those with commercial coverage, Medicare Advantage, and Medicaid managed care consistent with state and federal regulations.
Source:
https://www.ahip.org/news/press-releases/health-plans-take-action-to-simplify-prior-authorization
Quality Payment Program Claim Adjustment Applied to Correct Conversion Factor
The Centers for Medicare & Medicaid Services has found a system issue related to the 2026 Medicare Physician Fee Schedule conversion factors.
Updated CDLT Data Reporting Period to Begin May 1
Effective May 1, clinical diagnostic laboratories will be required to follow new data reporting requirements for clinical diagnostic laboratory tests...