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Medical billing, coding, denials, credentialing, PCMH and practice operations, written to be useful on Monday morning.
UnitedHealthcare April 2026 Bulletin: PC/TC Edits and Genetic Test Authorization
UnitedHealthcare's April 2026 bulletin brings a PC/TC policy change for radiology billed with an E/M from April 1, new genetic and molecular codes needing prior authorization for commercial and exchange plans, and Gold Card list changes. Here is what to check in your charge master and authorization lists.
Payers Must Post Prior Authorization Metrics by March 31, 2026: How to Read Them
Under CMS-0057-F, Medicare Advantage, Medicaid managed care, CHIP and exchange plans must publish their 2025 prior authorization approval, denial, appeal and turnaround numbers by March 31, 2026. Here is where to find them, what they can and cannot tell you, and how to use them in appeals and contract talks.
The Marketplace 90-Day Grace Period: Why Claims Pend in Months Two and Three
Eligibility says active, the claim goes out, and nothing comes back for weeks. The patient is in the Marketplace 90-day grace period, and the plan may hold your claim until the premium is paid or coverage is cancelled retroactively. We explain the rule, why 2026 is a bad year for it, and how to protect the practice.
HEDIS Chart Review Season Runs February to May 2026: How to Handle Requests
Health plans are pulling charts for HEDIS measurement year 2025 from February through May 2026. Here is what the requests are, why HIPAA allows you to answer them, how to run the work without losing a medical records clerk for a month, and how to cut next year's volume with CPT Category II codes.
Medicare Advantage vs Original Medicare Billing: The Differences for Practices
More than half of Medicare patients now arrive with a plan card rather than a red, white and blue one, and the billing rules change with it. We lay out the Medicare Advantage vs Original Medicare billing differences a practice feels: who to bill, authorizations, rates, timely filing and appeals.
UnitedHealthcare Anatomical Modifier Policy Starts February 1, 2026: A Checklist
For dates of service on or after February 1, 2026, UnitedHealthcare commercial and exchange plans require the most specific anatomical or laterality modifier on surgical and radiology codes, and lines without it may deny. Here is the modifier table, the codes most at risk and the scrubber rules to add.
Medicare Advantage Open Enrollment Runs Through March 31, 2026: A Practice Plan
The Medicare Advantage Open Enrollment Period runs January 1 to March 31, 2026, and this year it follows a record wave of plan exits. Patients who switched, or were switched, are arriving with cards that do not match your file. Here is what the period allows and the checks to run.
Payer Contract Terms Explained: The Clauses That Decide What You Get Paid
Most practices sign payer agreements without reading past the rate exhibit. Here is a plain-language guide to the terms that govern your revenue: lesser-of language, fee schedule references, timely filing, recoupment lookbacks, all-products clauses, amendment by notice and termination.
Prior Authorization Clocks Start January 1: 72 Hours, 7 Days, a Written Reason
CMS-0057-F now requires Medicare Advantage, Medicaid and CHIP plans to decide urgent prior authorization requests within 72 hours and standard requests within seven calendar days, and to give a specific denial reason. Here is what changed on January 1 and how to hold payers to it.
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