Category: #Medicareadvantage

Posted in #Medicareadvantage, #reimbursement, MVP (NY/VT) Insurance Payer, NY Providers, Payer Updates, Payers and CPT reinbursement, Training, Updates

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

Posted on 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:

  1. Oral only Phosphate binders for ESRD members no longer will be dispensed through the pharmacy NYRx benefit
  2. The Phosphate binders will be dispensed by the dialysis center
  3. Reimbursement- no separate reimbursement will be made for oral only phosphate binders instead it is included in the new APG dialysis rate
  4. Dialysis centers should not bill a separate claim for these phosphate binders (ESRD patients)
  5. 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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Posted in #Medicareadvantage, #unitedhealthcare, NY Providers, Prior Authorization Insurance Carrier Updates

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

Posted on 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:

Image via UHC website

For a full list of affected codes please click here: https://www.uhcprovider.com/en/resource-library/news/2025/removal-prior-auth-radiology-cardiology.html

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Posted in #Medicareadvantage, MVP (NY/VT) Insurance Payer, Prior Authorization Insurance Carrier Updates, Updates

MVP to end its relationship with naviHealth, Inc

Posted on by KR2Medical Billing

Currently naviHealth, Inc handles Utilization and Case/Care Management for post-acute services—including Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), and Home Health—for MVP Medicare Advantage, DualAccess, and DualAccess Complete Members.

However, MVP and naviHealth, Inc will end their contract as of Dec 31st 2025.

Starting on Jan 1,2025 MVP will process these requests in house.

More information to come in Nov 2025.

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