Notices & Updates

Preauthorization requirement for outpatient surgeries effective July 1, 2026

PEHP is committed to helping our members receive high‑quality, cost‑effective care in the most appropriate setting. To support this goal, we are implementing the following updates:

Preferred Site of Service: Ambulatory Surgical Centers

Effective July 1, 2026, Ambulatory Surgical Centers (ASCs) will be the preferred site of service for elective outpatient total hip, knee, and shoulder arthroplasty procedures. When clinically appropriate, these procedures are expected to be performed in an ASC.

Preauthorization (PA) Requirement for Outpatient Hospital

Effective July 1, 2026, preauthorization will be required for elective total hip, knee, and shoulder arthroplasty procedures when performed in an outpatient hospital setting. Authorization will be approved when one of the following criteria is met:

• When the patient’s medical or surgical complexity exceeds ASC capabilities; or
• No ASC is available within a convenient driving distance from the patient’s home.

The policy and PA form are available in the Provider Portal under the Resources menu.

If you have any questions, please contact us via the Message Center in the Provider Portal.

Infusion medication site of service changes effective July 1

Effective July 1, 2026, all infusion medications must be administered in a home health environment or infusion center instead of an outpatient hospital setting, unless an outpatient hospital setting is medically necessary and authorized by PEHP. Current PEHP members who are already receiving infusion medications in an outpatient hospital setting will be required to transition to a home health environment or infusion center by September 1, 2026.

If you have any questions, please contact us via the Message Center in the Provider Portal.

2026 Medical Fee Schedule Notice

Per your Provider Agreement Section 5.4, this serves as Notice that PEHP will be updating the medical reimbursement fee schedule effective July 1, 2026.  

As part of our annual review process, the updated medical fee schedule reflects the CMS 2026 Relative Value Units (RVUs). To see how this may impact your reimbursement, use the Fee Schedule Lookup tool in your PEHP Provider Portal. You can compare past and current fees and download them to Excel. The 2026 fee schedule will be available for your review online no later than July 15, 2026.

If you have any questions, please contact us via the Message Center in the Provider Portal.

Per Diems for Physical Therapy/Occupational Therapy

Physical therapy and Occupational Therapy shall be reimbursed at a rate of a maximum of $91.16* per diem (per day) for all services provided regardless of the services or number of modalities provided.

Contracted providers are obligated to accept this amount as allowed in full and may not balance bill member.

For services not included in the per diem maximum, i.e. E&M, labs, x-rays, etc., provider shall be compensated an amount (less applicable co-payments, coinsurance, and/or deductible) equal to the lesser of the billed amount or the allowed amount as determined by PEHP and indicated on the EOB and Provider Remittance.

Providers may download their Fee Schedule in the PEHP Provider Portal*.

*Effective July 1, 2026, the maximum rate will be $91.62. Please be advised the Fee Schedule will show allowed amounts on the individual code. Should an amount for any one code be less than the per diem on its own, or when billed with additional codes whose allowed amounts, when combined, are less than the per diem, PEHP will apply the full allowed amount to that code(s). Otherwise, all codes will be combined with the allowed amount not to exceed the per diem rate.

Anesthesia Rate Information and Sample Calculation

Anesthesia Reimbursement Rates effective July 1, 2024 to current (Per 12-Minute Unit):

• MD’s (Anesthesiologists): $68.53*

• CRNA’s (Certified Registered Nurse Anesthetists): $63.18*

*These rates are based on current community-based anesthesia conversion factor. However, some providers may have different rates based on their specific group contract.

Sample calculation for Time-Based Anesthesia Reimbursement:

Based Unit + Time Units + Modifier Units + Physical Status Units (if applicable) X Conversion Factor.

• Base Unit: Represents the base unit value of the complexity of the service, and includes the preoperative, anesthesia procedure, and post-operative.

• Time Unit: Represents the time spent providing anesthesia, which we allow in 12-minute increments.

• If only total time is provided (not time units), divide the total time by 12 to determine the number of time units.

• Any remaining portion (even if less than 12 minutes) is counted as one full unit.

Sample calculation for Non-Time-Based Procedures:

• For procedures not based on time, reimbursement is calculated using the CMS Resource-Base Relative Value System (RBRVS) for Utah.

Sample calculation Example Using Based Units:

Based Units: 5 Time: 45 minutes = 4 time units

• 3 full units (12 x 3=36 minutes)

• 1 unit (remaining 9 minutes)

Modifier Units: 1

Physical Status Units: 1

Conversion Factor: $XX.XX – Total Reimbursement

ASA = American Society of Anesthesiologists

RVU = Relative Value Unit: are standard units that place a value to each unit of service assigned to each CPT code.

Miscellaneous Payment Terms

ASP-based allowances

PEHP allows 112% of the Average Sales Price (ASP). If a code is not included in the ASP schedule or if it is a vaccine or immunization, PEHP applies the following:

• Vaccines: Allowed at 100% of the Average Wholesale Price (AWP).
• Non‑vaccine: Allowed at 94% of AWP.

When PEHP pays based on AWP, the allowance is determined using the National Drug Code (NDC).

Telemedicine Services

Telemedicine services are allowed at 90% of the rate for an in‑person visit.

Laboratory Services

Laboratory services are allowed at 100% of the current CMS Clinical Laboratory Fee Schedule. Toxicology pays at a different rate.

National Drug Code Billing Requirement

Affected Providers

• Hospitals
• Other providers billing for services under the Inpatient Prospective Payment System (IPPS) and/or Outpatient Prospective Payment System (OPPS).
• Professional claims with physician-administered drugs.

Action Needed

• Make sure your reimbursement staff knows about the NDC billing requirement and any documentation requirements starting January 1, 2023.
• Claim lines will begin to deny effective date of service on or after January 1, 2023, if the HCPCS code is not present when an NDC is not billed.

Background

• PEHP requires the use of NDCs and related information when drugs are billed for professional, ancillary and facility electronic (ANSI 837P). PEHP requires inclusion of the NDC along with applicable Healthcare Common Procedure Coding System (HCPCS) or Current Procedure Terminology (CPT) code(s) on claim submissions for unlisted or “Not otherwise Classified” (NOC) or “Not Otherwise Specified” (NOS) physician administered and physician supplied drugs.
• “NDC” stands for National Drug Code. It is a unique, 3-segment numeric identifier assigned to each medication listed under Section 510 of the U.S. Federal Food, Drug and Cosmetic Act. The first segment of the NDC identifies the labeler (i.e., the company that manufactures or distributes the drug). The second segment of the NDC identifies the product (i.e., specific strength, dosage form, and formulation of a drug). The third segment identifies the package size and type. For billing purposes, the Centers of Medicare and Medicaid Services (CMS) created an 11-digit NDC derivative, which necessitates padding of the labeler (5 positions), product (4 positions) or package (2 positions) segment of the NDC with a leading zero, thus resulting in a fixed-length, 5-4-2 configuration.
• NDC is usually found on the drug label or outer packaging. The number on the packaging may be less than 11 digits. The label also displays information about the NDC unit of measurement drug.
• If the medication comes in a box with multiple vials, use the NDC number on the box (outer packaging).