Currentpriority healthPolicy 086

ORDERING / REFERRING PROVIDER REQUIREMENTS

Defines the requirements, documentation, and billing rules for providers who order or refer services on behalf of Priority Health members; applies to providers submitting claims to Priority Health.

Policy Summary

Payerpriority health

PolicyOrdering / Referring Provider Requirements

Policy CodePolicy 086

Change TypeNo material changes

Effective Date

Next Review DateApr 1, 2026

Key ActionEnsure ordering/referring providers have an individual NPI, are enrolled with Priority Health, and are of an eligible specialty when submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13eligible provider specialties listed

DMEPOS, lab, radiologyservice categories requiring info

requireddocumentation

Apr 2026next review

Ordering and Referring Provider Requirements

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.

ALL of the following

Have an individual National Provider Identifier (NPI)
Be enrolled with Priority Health in either an 'approved' or an 'opt-out' status
Be of an eligible specialty type (eligible specialty types include: Doctor of Medicine or osteopathy; Doctor of Dental Medicine; Doctor of Dental Surgery; Doctor of Podiatric Medicine; Doctor of Optometry — Optometrists can only order DMEPOS supplies and laboratory or x-ray services payable under Medicare Part B; Physician Assistants; Clinical Nurse Specialists; Nurse Practitioners; Clinical Psychologists; Interns, Residents and Fellows; Certified Nurse Midwives; Clinical Social Workers)
Document medical necessity of ordered services in the patient record; ordering provider remains responsible for medical necessity even if another entity performs the test
Maintain complete and accurate documentation of orders and referrals and make order/referral documentation available upon request; charges may be denied for services lacking appropriate documentation
Apply modifiers in accordance with CMS NCCI guidance and only when supported by documentation; incorrect modifier application may result in denials
Understand that authorization requirements and medical necessity appropriate to procedure, diagnosis and frequency still apply; an authorization is not a guarantee of payment and does not supersede coding, billing, or reimbursement requirements

ALL of the following

Examples of service categories requiring ordering/referring information
- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS)
- Clinical laboratory and pathology services
- Radiology services

ALL of the following

Failure to follow applicable government program regulations, policy or contractual requirements may result in claim rejection or denial and potential recovery/recoupment of payments
Priority Health may perform pre- or post-claim payment integrity reviews to validate billing and coding accuracy

Service Categories and Modifier Rules

Service categories requiring ordering/referring infomixedCovered

DMEPOS	Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS)
Clinical laboratory/pathology	Clinical laboratory and pathology services
Radiology	Radiology services

Service categories requiring ordering/referring infomixedCovered

DMEPOS	Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS)
Clinical laboratory/pathology	Clinical laboratory and pathology services
Radiology	Radiology services

Modifier application

Modifier policyPriority Health follows CMS NCCI; modifiers must be applied per that guidance and only when supported by documentation

Documentation requirementModifier use must be supported by documentation in the medical record

Denial riskIncorrect application of modifiers may result in claim denials

Reference for detailsSee Priority Health Provider Manual for further guidance on modifier use

Authorization and Billing Notices

Prior Authorization

Authorization may be required — check Provider Manual

Coverage will be considered for services furnished in the appropriate setting to the patient's medical needs and condition. Authorization may be required; see the Provider Manual for details on when prior authorization is necessary.

Billing Rule

Authorization is not a guarantee of payment

An authorization is not a guarantee of payment and does not supersede coding, billing, or reimbursement requirements; claims may be denied or recouped if billing, coding, documentation, or policy requirements are not met.

Proper billing and submission guidelines (CPT, HCPCS, revenue codes) must be followed and supported by documentation.
Failure to document services or follow government/program regulations may result in claim denial, rejection, or recovery.
An authorization on file does not supersede coding, billing, or reimbursement requirements.

Key Definitions

Ordering and referring provider definitions

Ordering provider definitionOrdering providers can order nonphysician services for patients.

Referring provider definitionReferring providers can request items or services which Priority Health may reimburse on behalf of its members.

Documentation expectationOrders and referrals should be documented in the patient record and available on request

Referring provider reimbursement requests

Referring provider authorityReferring providers may request items or services that Priority Health may reimburse on behalf of members.

Payment conditionReimbursement by Priority Health is contingent on policy coverage, documentation, and billing rules

Record retentionRequests and supporting documentation should be maintained in the member's medical record for review

Policy Summary

Payerpriority health

PolicyOrdering / Referring Provider Requirements

Policy CodePolicy 086

Change TypeNo material changes

Effective Date

Next Review DateApr 1, 2026

Key ActionEnsure ordering/referring providers have an individual NPI, are enrolled with Priority Health, and are of an eligible specialty when submitting claims.

SourceLink

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