CLAIMS & REIMBURSEMENT

Reimbursement Policy Updates

Medical Associates Health Plan reimbursement policies have been updated and are available online:

• Medical Associates Health Plans
• Health Choices
• Central Plains Physicians Health Plan

Key updates include:

• Medication reimbursements
• Non-payable items, services, and therapies
• Blood and blood processing
• Unbundling and overbilling
• Medical orders

Please review these updates to help ensure accurate claim submission and timely reimbursement.

Claims Review & Documentation

Medical Associates Health Plan uses national benchmark data to help ensure billing aligns with expected utilization patterns. Providers exceeding 20% above benchmark thresholds may be subject to additional review.

Review areas include:

• E&M Services: Reviewed by specialty using MGMA benchmarks
• Psychotherapy Services: Records may be requested to validate time-based claims
• Chiropractic Services: Periodic review of a 10-claim sample by a licensed chiropractor

Timely and complete documentation responses can help prevent payment delays. Full audit details are available in the reimbursement policies.

Reconsideration Requests

Requests for reconsideration of adverse benefit determinations must be submitted through the provider portal within the timely filing requirements.

NDC Codes Now Required

National Drug Code (NDC) information is now required for applicable claims. Please ensure the following fields are completed accurately:

For paper claims (CMS-1500), include the following in the shaded portion of line-item field 24A–24G:

• Enter the NDC qualifier N4 (left-justified), followed immediately by the NDC
• Add one space, then the unit of measure qualifier (UN, ML, GR, or F2)
• Follow with the quantity (number of NDC units)

CREDENTIALING & PROVIDER INFORMATION

Report Provider Changes Promptly

Please report additions, terminations, or demographic changes using the Provider Add, Term, Change Form:

• Medical Associates Health Plans
• Health Choices
• Central Plains Physicians Health Plan

If your office changes credentialing vendors or staff, please notify us at mahpcredentialing@mahealthcare.com.

PHARMACY & FORMULARY UPDATES

Several formulary updates will take effect July 1, 2026, including shifts to generic preferred medications and coverage changes for certain products. We recommend reviewing these updates to help support smooth transitions for your patients.

Generic Preferred Medications

The following brand medications will move to generic preferred status:

• Spiriva HandiHaler®
• Dificid®
• Premarin® tablets

No new prescriptions required—pharmacies will dispense generics automatically when available.

Animal-Derived Thyroid Products

NP Thyroid® and Armour Thyroid® will be excluded from coverage effective July 1, 2026, due to safety and regulatory considerations (not FDA-approved).

Clinical guidance:

Patients currently using these products should be encouraged to discuss conversion to synthetic levothyroxine and/or liothyronine as appropriate.

Reminder:

Brand Synthroid® remains excluded and will only be considered for coverage when clinical documentation and lab data show inadequate thyroid control with a generic formulation.

Medical Pharmacy & Oral Oncology Updates

Denosumab (Prolia® and Xgeva®)

• Biosimilar formulations will be preferred
• No prior authorization required for biosimilar use
• No specific biosimilar is required at this time

Tasigna® (nilotinib)

• Generic nilotinib is now the preferred formulation

Lenalidomide (Revlimid®)

• Generic supply is stabilizing, with full availability expected within six months
• Generic lenalidomide remains a Tier 1 formulary option
• Revlimid® will remain Tier 2

RESOURCES