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Aetna Medicare Advantage: reminder- certain post acute, skilled nursing and home health require pre- approval

Posted on January 20, 2026 by KR2Medical Billing

This change applies to the providers located in the following states:

NJ, NY, PA, VW

The pre-apporoval applies to some post-acute , skilled nursing, and home health services.

The following HCPCS are affected:

G0151: Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
G0153: Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
G0155: Services of a clinical social worker in home health or hospice settings, each 15 minutes.
All the codes until G0162

As well as the following codes:

G0299- Direct skilled nursing services of a Registered Nurse (RN) in the home health or hospice setting, each 15 minutes.

G0300-Direct skilled nursing services of a Licensed Practical Nurse (LPN) in the home health or hospice setting, each 15 minutes.

G0463- Skilled services by a Registered Nurse (RN) for observing and assessing a patient’s condition.

G0496- Skilled services by a Licensed Practical Nurse (LPN) for training or educating a patient or family member.

Inpatient Revenue code:

128- daily medical management, skilled rehab services, and regular physician (MD/NP/PA) oversight for intensive rehab patients

Skilled Nursing levels: 1,2,3,4.

Pre-auth process:

1. Go to EviCore.

2.Call 1-888-622-7329 during normal business hours.

3.Fax a request form to 866-705-3574 (Aetna Home Health), 855-633-8631 (AETNA PAC Initial) or 877- 502-0810 (AETNA PAC Concurrent)

For any urgent requess, when member requires services in less than 48 hours, please call eviCore.

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Oral-Only Phosphate Binders reimbursement- MVP Medicaid, HARP plans

Posted on January 19, 2026 by KR2Medical Billing

To align with NYS Medicaid ESRD reimbursement for oral-only phosphate binders- MVP will include the reimbursement in the newly aligned Dialysis center APG reimbursement. Effective for any DOS 1/1/2026.

Higlights:

Oral only Phosphate binders for ESRD members no longer will be dispensed through the pharmacy NYRx benefit
The Phosphate binders will be dispensed by the dialysis center
Reimbursement- no separate reimbursement will be made for oral only phosphate binders instead it is included in the new APG dialysis rate
Dialysis centers should not bill a separate claim for these phosphate binders (ESRD patients)
Oral only phosphate binders affected by this change: sevelamer carbonate, lanthanum carbonate, sucroferric oxyhydroxide, and ferric citrate.

NYS APG rate:

The FFS APG weight for APG 168 (dialysis) has increased from 1.3651 to 1.5302.

For the NYS Medicaid announcement click here .

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UHC to remove prior auth for some radiology and cardiology tests.

Posted on December 13, 2025 by KR2Medical Billing

Starting Jan 1, 2026 certain nuclear imaging tests, OBGYN ultrasounds, and certain cardiology tests will no longer require a prior authorization for some of the following plan types:

1.UnitedHealthcare Insurance Company
2.UnitedHealthcare Mid-Atlantic, inc.
3.UnitedHealthcare Plan of the River Valley, Inc. and 4.UnitedHealthcare Insurance Company of the River Valley
5.Oxford Health Insurance, Inc.
United Healthcare Level Funded (formerly All Savers Life Insurance Company of California)
6.Neighborhood Health Partnership, Inc.
7.UnitedHealthcare Individual Exchange plans, also referred to as UnitedHealthcare Individual and Family ACA Marketplace plans
8.UnitedHealthcare Services, Inc.
9.UnitedHealthcare Community Plans

Some of the affected codes are: