Effective Date: Dec. 22, 2026

Health Plans Affected: Advantage MD (AMD), Employer Health Programs (EHP), Priority Partners, and US Family Health Plan (USFHP)

Type of Change: New Policies, Policy Updates and Reminders
 
Explanation of Change:

Johns Hopkins Health Plans has created new and updated existing reimbursement policies, as listed below:

Reminders About Johns Hopkins Health Plans Reimbursement Policies
Unless otherwise specified, Johns Hopkins Health Plans reimbursement policy guidance applies to all items and services reported on CMS-1500/837P and UB-04/837I claim forms, when submitted by a health care professional, provider, supplier or facility, regardless of network participation (in-network or out-of-network) status.

Provider: Any individual or entity that is licensed, certified, or otherwise authorized under applicable state and federal laws to furnish, bill for or receive reimbursement for covered health care services, items, or supplies.

Providers are required to submit clean claims using industry‑standard compliant coding on all claim submissions and to review our Reimbursement Policies to identify any instances where the plan’s billing requirements may differ.

Reminder When Billing for Outpatient Hospital Services:

• Johns Hopkins Health Plans requires all outpatient facility claims to be reported with claim line-level details (e.g., dates of service, units, diagnosis codes, condition code, rev code, procedure code, applicable modifier, etc.).
• When a revenue code is reported without a HCPCS/CPT code or the appropriate procedure code, the service will be denied.

Please see the Reimbursement Policy Chart for 12-22-26 for details.

Same Day Services (RPC.054) – New Policy

• When a claim includes multiple, identical, same or similar/like services reported for the same member on the same date of service and is submitted without supporting documentation demonstrating that these services are distinct and separately identifiable, medically necessary, and independently covered, Johns Hopkins Health Plans will adjust, reduce, or deny payment.

Laboratory Panel Testing (RPC.056) – New Policy

• When two or more single component codes are separately billed by the same provider, for the same date of service, reimbursement is based on the lesser amount for the sum of the charges of the individual tests or the panel rate, unless an exception applies.
• Johns Hopkins Health Plans reserves the right to bundle the individual components and reimburse the most appropriate panel code, as determined by the plan.
• The plan will only reimburse one Gastrointestinal pathogen (GIP) multiplex panel (CPT code 87505, 87506 or 87507) per day per member, by the same or different provider.
• Per CMS guidance, when respiratory panels that evaluate more than 5 respiratory pathogens are furnished in the outpatient setting, they are considered not medically reasonable and necessary and will not be reimbursed.

Updated Policies: Laboratory Services (RPC.034)

Policy guidelines have been updated to incorporate multiple billing and coding revisions that may affect reimbursement for certain services. These updates ensure continued alignment with regulatory requirements, industry standards, and organizational directives. Changes include, but are not limited to:

o Policy template update
o Enhanced policy language
o Updates to billing and coding guidance in alignment with authoritative rules and regulations, applicable to the relevant health plan(s)
o Updated lists, tables, references, and definitions within the policy
o Removal of deleted codes and outdated guidance

REFERENCES

• CMS Regulations & Guidance
• COMAR- Maryland Department of Health (MDH)
• CPT® Copyright American Medical Association
• JHHP Reimbursement Policies• MDH Provider Information Site
• NCCI for Medicare | CMS• NCCI for Medicaid | CMS
• Novitas Solutions- Medicare Administrative Contractor
• TRICARE® Manuals