Gender-specific services

Claims for gender-specific services will deny when a member is in our records as one gender but the services rendered are billable only for a different gender.

When a member is transitioning from one gender to another or is transgender and the services are appropriate, you can avoid these automatic claim denials.

Use condition code 45

Priority Health follows the CMS CR 6638 Medicare process for members of all commercial, Medicare and Medicaid plans. It instructs providers submitting inpatient and outpatient claims for transgender and transitioning patients to report condition code 45 (ambiguous gender category). This allows the gender-related edits to process correctly.

Providers will then be reimbursed for the service if coverage and reporting criteria are met.

Encourage patients to contact our Customer Service

We cannot change a member's gender in our records to ensure claim processing. However, our members can call Priority Health Customer Service and self-declare as transgender or as transitioning. This updates our member records and will trigger review instead of automatic denial for gender-specific claims. 

Medical policy