Currentpriority healthPolicy 024

OPPS STATUS INDICATORS

Defines payment and billing status indicators (CMS PFSRV) as adopted by Priority Health for physician and non-physician practitioner services and how those indicators affect reimbursement and claim handling.

Policy Summary

Payerpriority health

PolicyOPPS STATUS INDICATORS

Policy CodePolicy 024

Change TypeExceptions addedtitle reviseddisclaimer added

Effective Date

Next Review DateFeb 5, 2025

Key ActionObtain and document required authorizations and medical necessity; authorization does not guarantee payment.

SourceLink

POLICY UPDATE CHANGES

Added 'Exceptions' section with exception information for status indicator B and counseling information specific to CPT 96041.

Added 'Disclaimer' section.

Changed policy title From 'Professional status indicators' to OPPS Status Indicators.

12distinct status indicator definitions provided (B, P, T, E, I, N, X, M, NA plus bundled/other sections)

CPT 96041explicit exception code called out for reimbursement guidance

QuarterlyPFSRV update cadence

Applies toApplies to

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.

How Status Indicators Affect Coverage

Coverage rules by status indicator

Status indicators determine whether codes are reimbursed, bundled, excluded, informational, or require alternative payment handling; exceptions and provider responsibilities apply.

ALL of the following

Outcome: No separate reimbursement; always bundled into other services; may be defined as covered but no payment assigned
Operational: Services designated as status B aren't reimbursed even when billed alone

ALL of the following

Outcome: Reimbursed when billed alone or with another P-designated service
Definition: Status P commonly characterizes supply codes and are inclusive when performed same date of service

ALL of the following

Condition: Injection performed same date by same provider with other physician services
Outcome: Considered inclusive to payable physician services; reimbursement made only if no other physician fee schedule services are performed

ALL of the following

Outcome: No PFS payment; no RVUs or fee schedule amounts shown
Operational: When covered, payment continues under reasonable charge procedures; exclusions for pharmacy/biologics detailed in the Provider Manual

ALL of the following

Outcome: Claim denied for inaccurate or invalid code
Operational: Provider is responsible to report the most accurate code and must resubmit claims after denial

N or X - Medicare/statutory exclusions

N: Applies when CMS defines service as non-covered under traditional Medicare (applies to Medicare products only)
X: Statutory exclusions outside physician services; no RVUs/fees assigned; consult Provider Manual or contracts for alternative fee schedules or handling (applies to Medicare products only)

ALL of the following

Outcome: Typically no fee assigned; identifies performance measurement or set criteria
Operational: Services payable only if defined through an eligible initiative in the Provider Manual

ALL of the following

Outcome: Rarely or not reimbursed in non-facility or facility settings per the physician fee schedule
Operational: Exceptions to reimbursement based on setting are defined in the Provider Manual

Exception - Genetic counseling (CPT 96041)

Condition: CPT 96041 is assigned status indicator B
Outcome: Reimbursed only when provided by trained genetic counselors per CPT guidelines
Operational: When genetic counseling and education are provided by a physician or other qualified health care professional who can report E/M services, the appropriate E/M code must be used per CPT guidelines

Authorization and documentation requirements

Condition: Authorization on file or service performed
Operational: Authorization and medical necessity requirements are still required; an authorization isn't a guarantee of payment
Operational: Proper billing, coding, and documentation must support codes billed; failure to document may result in denial, claim rejection, or recovery/recoupment

Status Indicators, Code Groups, and Update Cadence

Status Indicator B (example exception) - CPT CodesCPT

96041

Medical genetics and genetic counseling services, each 30 minutes

Status Indicator B - Definitionsmixed

B	Services that are always bundled and not assigned relative value units (RVUs) or payment; not reimbursed when billed alone

Status Indicator P - Covered CPT/HCPCSmixedCovered

P	Services typically considered inclusive to other physician services or supply codes; reimbursed when billed alone or with another P-designated service

Status Indicator T - Covered CPT/HCPCSmixedCovered

T	Injection services considered inclusive to payable physician services when performed same date by same provider; reimbursement only if no other physician fee schedule services performed

Status Indicator E - Not covered under PFS (may be paid under reasonable charge)mixedNot Covered

E	Codes excluded by CMS from physician fee schedule payment; no RVUs or payment shown; may be paid under reasonable charge procedures

Status Indicator I - Invalid codesmixedNot Covered

I	Codes reported that are invalid; provider must report the most accurate code and resubmit after denial

Status Indicator N - Medicare non-coveredmixedNot Covered

N	Services CMS defined as non-covered under traditional Medicare (applies to Medicare products only)

Status Indicator X - Statutory exclusionsmixedNot Covered

X	Items or services considered statutory exclusions outside physician services; no RVU/fees assigned (applies to Medicare products only)

Status Indicator M - Informational/reporting onlymixed

M	Services reporting only, typically no fee assigned; payable only if defined through eligible initiative in Provider Manual

Status Indicator NA - Setting-based nonpaymentmixedNot Covered

NA	Items or services rarely or never reimbursed when performed in non-facility settings or not paid in a facility setting based on the physician fee schedule; exceptions in Provider Manual

PFSRV update cadence

PFSRV update cadencePriority Health aligns updates with CMS Physician Fee Schedule Relative Value (PFSRV) releases on a quarterly basis

Status Indicator Definitions

Physician Fee Schedule Relative Value file (PFSRV)

DefinitionPhysician Fee Schedule Relative Value (PFSRV) file defines payment status indicators for codes listed in the CMS physician fee schedule

RoleStatus indicators in the PFSRV classify codes for claims processing and whether they will be reimbursed

Use by Priority HealthPriority Health adopts PFSRV status indicators and may update payment decisions in alignment with CMS quarterly releases

Bundled indicators

DefinitionBundled indicators identify items or services that are inclusive or bundled into another physician service when minimal additional resources are required

ApplicationThese services are always bundled into reimbursement for the more complex service performed on the same date of service

Billing, Authorization, and Recovery Actions for Providers

Prior Authorization

Authorization and Payment Caveat

Authorization requirements and medical necessity appropriate to the procedure, diagnosis and frequency remain required. An authorization is not a guarantee of payment and does not supersede coding, billing or reimbursement requirements; providers must submit industry-standard CPT/HCPCS/revenue codes only for services actually performed and fully documented in the medical record to the highest level of specificity.

Ensure authorization and medical necessity are documented for the specific procedure, diagnosis and frequency.
Report CPT, HCPCS and revenue codes only when the service was performed and fully documented.
Understand that an authorization on file does not override coding, billing or reimbursement rules.

Denial Risk

Claim Denial and Payment Recovery Risk

Priority Health may reject or deny claims or recover/recoup payments if government program regulations, policy guidance or contractual requirements are not followed; failures in documentation, coding or adherence to billing policies can trigger pre- or post-claim payment integrity reviews and recoupment actions.

Policy Summary

Payerpriority health

PolicyOPPS STATUS INDICATORS

Policy CodePolicy 024

Change TypeExceptions addedtitle reviseddisclaimer added

Effective Date

Next Review DateFeb 5, 2025

Key ActionObtain and document required authorizations and medical necessity; authorization does not guarantee payment.

SourceLink

On This Page

ImplicationAlthough a service may be designated 'covered', no separate payment is made when it is bundled

Status Indicator B

DefinitionStatus Indicator B: services that are always bundled and are not assigned relative value units (RVUs) or payment

Billing implicationThese services are always bundled into other services' reimbursement and are not reimbursed when billed alone

Coverage noteA service may be defined as covered but have no separate reimbursement because it is designated B

Status Indicator P

DefinitionStatus Indicator P: services commonly characterized as supply codes and considered inclusive to other physician services performed same date

Payment ruleServices with status P will be reimbursed when billed alone or when billed with another P-designated service

Typical useOften used for supply-type services that may be payable standalone

Status Indicator T

DefinitionStatus Indicator T: injection services considered inclusive to any payable physician services when performed same date by the same provider

Payment ruleReimbursement for T-designated injection services is only made if no other physician fee schedule services are performed

ScopeApplies when injections occur on the same date of service by the same provider as other payable services

Status Indicator E

DefinitionStatus Indicator E: codes CMS excluded from physician fee schedule payment by regulation

Payment implicationNo RVUs or fee-schedule payment shown; when covered, payment continues under reasonable charge procedures

Additional noteExclusions for pharmacy drugs or biologicals under medical benefits may be detailed in the Provider Manual

Status Indicator I

DefinitionStatus Indicator I: indicates codes reported that are invalid

Provider responsibilityProviders must report the most accurate code for services rendered and correct inaccuracies

Claim handlingInaccurate codes will be denied and require claim resubmission

Status Indicator N

DefinitionStatus Indicator N: services CMS defines as non-covered under traditional Medicare

ScopeApplies to Medicare products only; consult Provider Manual or member documents for enhanced/supplemental benefit exclusions

ImplicationNot covered under traditional Medicare; handling depends on product and contractual terms

Status Indicator X

DefinitionStatus Indicator X: statutory exclusions for items/services that fall outside physician services

Payment implicationNo RVUs or physician fee schedule fees assigned; services may be covered under other fee schedules per contract

ApplicabilityApplies to Medicare products only; reference Provider Manual or contracts for handling

Status Indicator M

DefinitionStatus Indicator M: informational or reporting-only services typically with no fee assigned

Payment exceptionServices are payable only if defined through an eligible initiative detailed in the Provider Manual

Use caseIdentifies measurements associated with defined performance measurement criteria

Status Indicator NA

DefinitionStatus Indicator NA: items or services that are rarely or never reimbursed when performed in a non-facility setting

Setting-based ruleAlso defines items/services that aren't paid in a facility setting per the physician fee schedule; exceptions are in the Provider Manual

ImplicationPayment depends on the setting; consult Provider Manual for exceptions

Failure to document services rendered or items supplied may result in denial and potential recoupment.
Priority Health may perform payment integrity reviews to validate billing and coding accuracy and to prevent fraud, waste and abuse.
Policies may be superseded by contract or law; Priority Health reserves the right to recoup payments to the effective dates of those requirements.