Pennsylvania providers: Benefit summary language updates

August 2024

We are making updates to the benefit summary for Pennsylvania. The purpose of these modifications is to provide clarification on medically necessary services and materials. Benefit coverage will remain unchanged. These modifications will also aim to eliminate the need for confirmations for the codes below and to clarify what is medically necessary. Currently, providers must obtain a confirmation number for the services below and with this change, providers will no longer have to request confirmations for these services.

All reviews will be performed through the claims process and a valid medical diagnosis is required for payment of any claims that are filed. Additionally, these improvements will reduce the load on providers and improve patient access to care. The standards for diagnostic codes will be included in all medical procedure policies and readily available on our on our Provider Reference Guide page starting Sept. 1, 2024.

You can still appeal claims and request clinical review of any contested claims. Our Peer Review Committee will review these requests to determine if they meet the requirements for medical necessity guidelines.

The procedures and states being updated effective Sept. 1, 2024, are as follows: