CMS issued updated instructions to Medicare Administrative Contractors (MACs) clarifying that payments for select claims affected by expired legislative Medicare coverage policies should be held; all others will be processed as usual. This announcement contradicts a previous CMS update from earlier that said payment for all Medicare Physician Fee Schedule claims would be held.
Unfortunately, this new announcement does not provide enough detail to fully understand which claims will be impacted. However, we do know that the expired legislative policies that CMS references include the temporary Medicare telehealth coverage flexibilities that have been in place since the COVID-19 pandemic and the 1.0 Geographic Practice Cost Index (GPCI) floor for Physician Work RVUs. Therefore, we expect claims for Medicare telehealth services (other than for behavioral or mental health care) and services provided in locations with a work geographic practice cost index (GPCI) below the 1.0 floor will continue to be held. Allergists working in nonimpacted geographic areas and those not providing telehealth services should see Medicare claims processed as usual.
Providers should continue submitting claims as usual, but payments for affected services outlined above will remain on hold until lifted, potentially avoiding widespread reprocessing.
Beginning Oct. 1, 2025, MACs were directed to hold all claims with dates of service on or after that date if the services are impacted by the now-expired Medicare payment provisions under the Full-Year Continuing Appropriations and Extensions Act, 2025.
Telehealth restrictions and ABN considerations
Without Congressional intervention, many Medicare telehealth services (excluding behavioral health) reverted to pre-COVID-19 Public Health Emergency restrictions as of Oct. 1, 2025. These restrictions prohibit services in beneficiaries’ homes or outside rural areas and require face-to-face hospice recertifications. Providers offering non-reimbursable telehealth services should consider issuing an Advance Beneficiary Notice of Noncoverage (ABN) to patients. Access ABN forms and instructions at CMS’s Beneficiary Notices Initiative. Monitor Congressional updates and consider holding non-payable telehealth claims.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
