Communications

Claims & payment changes effective January 1, 2026

Starting January 1, 2026, PEHP is implementing changes to its claims and payment processes. Please review the key changes below and plan accordingly to avoid delays:

What’s changing?

• Electronic claims required (see how). Paper claims will no longer be accepted.
• Dental preauthorization (PA) required for certain procedures. See list.
• Electronic payments only (see how to sign up for EFT). Otherwise, a $20 check fee will apply.

Why the changes?

• Faster claims processing: Our upgraded auto-adjudicating system processes claims in less than 10 days.
• Ensure medical necessity and prevent service duplication: Our new system is programmed to automatically detect and verify PA requirements during claim processing.
• Streamline payments: Paper checks create unnecessary administrative burdens for everyone – switching to EFT ensures you get paid faster.

If you have any questions or need support with these changes, please contact us via the Message Center in the New Portal or call 801-366-7555.

2025 Medical Fee Schedule Notice

This is a contractual notice that PEHP will be updating the medical reimbursement fee schedule effective July 1, 2025.

The updated medical fee schedule reflects the CMS 2025 Relative Value Units (RVUs). To see how this may impact your reimbursement, use the Fee Schedule Lookup tool in your PEHP Provider Portal at www.pehp.org. You can compare past and current fees and download them to Excel. The 2025 fee schedule will be available for your review online no later than July 15, 2025.

A Note About Contracts: To streamline our contracting process, we are transitioning all of our individual Provider Agreements to Group Provider Agreements as of July 1, 2025. If you already have a Group Provider Agreement, you do not need to do anything. This would allow additional providers in a group/office to be added to the same Tax Identification Number without recontracting.

Reminder! On July 1, a large part of our membership will be moved to our new claims payment system. The rest of our membership will be moved on September 1, 2025. For claims to process correctly, you must submit claims with the correct ID number and portal. Learn more.

We appreciate your cooperation and patience as we implement this important system upgrade.

Questions? Contact us via the secure Message Center in the New Provider Portal at www.pehp.org.

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).