Currentpriority healthPolicy N/A

Facility rate change letters

This billing policy governs submission and processing of CMS facility rate change letters for facility types (e.g., CAH, Children's Hospitals, Cancer Hospitals, RHC, FQHC) and describes how Priority Health uses those letters to determine facility reimbursement and processing timelines.

Policy Summary

Payerpriority health

PolicyFacility rate change letters

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionSubmit a fully completed CMS rate letter (including facility NPI tied to PTAN and contact information) to your contract administrator or via Prism; incomplete submissions will be returned.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthssubmit interval

30 dayssubmit within

30 daysprocessing allowance

1 or 15applied on

12 monthsreprocessing lookback

Submission and Processing Criteria

Submission and processing criteria

Covered when ALL of the following are met:

Facilities required to submit CMS rate letters include: Critical Access Hospitals (CAH); Children's Hospitals; Cancer Hospitals; Rural Health Clinics (RHC); Federally Qualified Health Centers (FQHC).

Priority Health requires the CMS rate letter for initial contract agreements and for all in‑network and out‑of‑network facilities.

Submission frequency and timing

No less than every 12 months.
Within 30 days of receiving an interim rate change notification (whichever is earlier).

Required submission data

Policy Summary

Payerpriority health

PolicyFacility rate change letters

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionSubmit a fully completed CMS rate letter (including facility NPI tied to PTAN and contact information) to your contract administrator or via Prism; incomplete submissions will be returned.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Reprocessing

Coding expectationsmixed

CPT/HCPCS/Revenue codes

Policy requires industry standard CPT, HCPCS and revenue codes for claim submissions and that services be documented to highest specificity.

Reprocessing lookback (inv-03)

Lookback period for reprocessingClaims may be reprocessed retrospectively up to 12 months if there is a decrease in payment.

When reprocessing appliesApplies when failure to submit updated CMS interim rate letters results in overpayment that reduces provider payment upon re-evaluation.

Effect on previously processed claimsIf a decrease in payment is identified, Priority Health will reprocess affected claims retroactively for up to 12 months.

LimitationsReprocessing lookback is limited to a 12-month retrospective period; claims outside this period will not be adjusted for decreases.

Submission Requirements and Channels

Billing Rule

Submission Requirements and Channels

Submit a CMS rate letter for initial contracts and for all in-network and out-of-network facilities listed below. Priority Health requires an updated CMS rate letter at least every 12 months or within 30 days of receiving an interim rate change notification letter (whichever is earlier). Allow 30 days for processing after Priority Health receives a fully completed rate change notification form and the submitted rate change letter. New rates will be applied to dates of service on the 1st or 15th of the month based on the date of receipt of a fully completed submission. Priority Health will not rely on the effective date shown on the CMS rate letter; the date of receipt and processing rules above control the applied effective date.

Facilities required to submit CMS rate letters: Critical Access Hospitals (CAH); Children’s Hospitals; Cancer Hospitals; Rural Health Clinics (RHC); Federally Qualified Health Centers (FQHC).
Include the facility National Provider Identifier (NPI) associated with the Provider Number / Provider Transaction Access Number (PTAN) and contact information for the facility with each submission.
Submissions with missing requirements will be returned to the facility for completion.
Failure to submit the CMS interim rate letter and applicable rate change letters will result in claims processing at the last verified rate. If a submitted rate change results in a decrease in payment, claims may be reprocessed retrospectively up to 12 months.
Submit CMS rate letters to your Contract Administrator or through Prism.

OpenPayer

Facility rate change letters

Submission and Processing Criteria

Coding and Reprocessing

Submission Requirements and Channels

Key Definitions