Category: Payer Updates

Posted in #aetna, Education, Payer Updates, Payers and CPT reinbursement, Training

AETNA Commercial Plans: compression supplies non covered codes.

Posted on by KR2Medical Billing

Please note that this policy update applies to the members that have commercial plan types.

The affected codes: for any DOS on or after Jan 1st 2026, Aetna will consider the following codes for compression stockings to be a disposable supply and a standard benefit exclusion.

Codes:

For Texas Providers:

These changes apply to fully insured plans written in Texas and only if such changes are in accordance with applicable regulatory requirements. Changes for all other plans will be as outlined in this article.

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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 #reimbursement, Education, NY Providers, Payer Updates, Payers and CPT reinbursement

NYS Medicaid POC Syphilis testing coverage

Posted on by KR2Medical Billing

Effective for any DOS August 2025 and thereafter Point of Care testing for Syphilis is covered for all fee fo service Medicaid and Managed Medicaid Members.

Where is this test covered (POS)?

physician/nurse practitioner/licensed midwife private office setting

What kind of POC is covered and reimbursed?

Currently there is only one FDA approved test -Clinical Laboratory Improvement Amendments-waived, rapid syphilis test, Syphilis Health Check™, for the detection of Treponema pallidum antibodies.

Coding:

86780 – Antibody; Treponema pallidum.

Reimbursement Rates:

Physician- https://www.emedny.org/ProviderManuals/Physician/ – select medicine fee schedule

Midwife- https://www.emedny.org/ProviderManuals/Midwife/ select fee schedule

Nurse Practitioner- https://www.emedny.org/ProviderManuals/NursePractitioner/

For more guidance on which providers are allowed reimbursement please read the NYS PDF file here.

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