Provider News & Info

Fall 2025

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 clean 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, contact us via the Message Center in the New Portal or call 801-366-7555.

How to submit medical and dental claims using the New Portal

Sign up or update EFT information

If you’re the Local Administrator for your organization, you can sign up or update EFT through the New Portal.

Here’s how:

1. Log in to the New Portal  and select Provider EFT Form from the Resources menu.
2. Complete the form. If you have different bank accounts for each location under the same Tax ID, select NO to the relevant question and submit information for each location.



Note: If you do not use a clearinghouse and plan to submit claims via the claim submission tool, enter N/A or None in the UHIN Assigned Trading Partner Number (HT#) field of the EFT update form.

Pharmacy changes effective January 1, 2026

Stelara no longer covered by PEHP

Stelara will no longer be covered on January 1, 2026. Instead, PEHP will cover two FDA-approved biosimilar alternatives: Yesintek and Selarsdi. These medications are clinically equivalent to Stelara in terms of safety, efficacy, and quality.

What this means for your PEHP patients:

• No preauthorization is required for Yesintek or Selarsdi.
• Submit a new prescription for the preferred biosimilar, effective January 1, 2026.
• Both medications will be covered at 100% after the patient meets any required deductible.
• Prescriptions can be filled at any network pharmacy.

If you have any questions, please contact the PEHP Pharmacy Department at (801) 366-7551.

Express Scripts (ESI) network change

Express Scripts (ESI) announced effective January 1, 2026, Cardinal Leadernet pharmacies will no longer participate in their network. If your PEHP patients currently fill prescriptions at any of these locations, please assist them in transferring their prescriptions to an in-network pharmacy.

Pharmacies affected include:

• Lin’s Pharmacy
• Fresh Market Pharmacy
• Macey’s Pharmacy
• Broulim’s Pharmacy
• Dan’s Drug
• Dick’s Pharmacy

For help finding an in-network pharmacy, members can contact Express Scripts at 877-231-4239.

Attention dental providers: Diagnosis code required for D9947

All claims for CDT code D9947 must include the appropriate ICD-10 diagnosis code(s) to support medical necessity. This is required by our new auto-adjudicating claims payment system.

Including the diagnosis will:

• Facilitate faster and accurate claim adjudication
• Minimize claim delays or denials
• Ensure compliance with documentation standards

What you need to do:

• Continue using CDT code D9947 for the procedure
• Add the corresponding ICD-10 diagnosis code(s) on the claim form

Your cooperation helps us streamline processing and ensures timely reimbursement. If you have questions, please contact us via the secure Message Center in the New Portal.

PEHP policy changes

Stay informed on new preauthorization (PA) requirements and policies to avoid delays in patient care.

Effective Immediately

• All claims for dental CDT code D9947 must include the appropriate ICD-10 diagnosis code(s) to support medical necessity.

Effective January 1, 2026

• Preauthorization is required for certain dental procedures. Learn More.
• Stelara will no longer be covered. Instead, PEHP will cover two FDA-approved biosimilar alternatives: Yesintek and Selarsdi.

You can view all PEHP clinical policies, authorization forms, and master policies via the New Portal. Here’s how:

1. Log in to the New Portal and choose Office Management--> Communications Archive from the menu on top.
2. Search a provider from your office.
3. Find the policy under the Document Type drop-down menu.
4. Complete form and return to us via Message Center in the New Portal.



Questions? Contact us via the Message Center in the New Portal or call us at 801-366-7555.

2025 fee schedule available online

On July 1, 2055, PEHP updated its reimbursement fee schedule to align with the CMS 2025 Relative Value Units (RVUs). To see how the fee schedule impacts 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 for easy reference.



Consistent taxonomy = Consistent payments

Taxonomies power the fee schedule that is used to process and pay claims. If a provider bills a different taxonomy on a claim than what is on file with PEHP, it will change the fee schedule used for that claim.

To avoid this issue, providers should review and confirm that the taxonomy billed on all claim forms matches the one on file with PEHP. If an update is needed, please fill out the Provider Account Information Form to request a change.

Coaching programs available through our partners

PEHP members have access to free health coaching for 3 months through our partners, AZOVA and Noble Health.

AZOVA - Free for 3 Months:

Members can work with licensed clinicians to tailor support just for them.

• Exercise, Nutrition, Sleep, Emotional Wellness
• Chronic Obstructive Pulmonary Disease (COPD)
• Hypertension
• Chronic Kidney Disease

Noble Health - Free for 3 Months:

• Weight Loss
• Parenting Resources

Encourage your patients to take advantage of these great benefits to improve their health.

How to contact us

Claims, provider portal, and other customer service items

If you need to report a new issue or have any concerns, the best way to reach us is via the secure Message Center in the New Portal. When calling us (801-366-7555), please select the correct queue within the provider phone tree to avoid longer wait times.

Important! If you need to send us documents, please use the Message Center.

PEHP Provider Contracts

If you have questions about your contract with PEHP, please contact the following:

Todd Sprouse, Director of Provider Contracting

801-803-0143

todd.sprouse@pehp.org

Mike Corrigan, Senior Provider Contracting Manager

801-597-5682

mike.corrigan@pehp.org

Cammie Keim, Provider Contracting Manager

801-366-7339

cammie.keim@pehp.org