CMS Appears to Lift Majority of Medicare Claims Holds

CMS issued instructions for the third time to Medicare Administrative Contractors (MAC) regarding processing of claims impacted by the expiration of certain legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025. 

The most recent update, issued on Oct. 21, directs MACs to lift the hold on claims processing and payment for certain services affected by select expired Medicare legislative payment provisions, including claims paid through the Medicare Physician Fee Schedule, ground ambulance transport claims, and Federally Qualified Health Center claims. Telehealth claims that CMS can confirm are definitively for behavioral and mental health services will also be processed and paid. It is unclear how CMS intends to address claims impacted by the expiration of the 1.0 Geographic Practice Cost Index floor applied to physician work in 39 states and territories around the country.

MACs will continue to hold claims for telehealth use for certain Evaluation and Management (E&M) services allowed by statute since the COVID-19 pandemic. Telehealth services are now limited to rural areas as before the COVID-19 public health emergency, and patients cannot receive telehealth services in their homes. The ability to provide audio-only services to Medicare patients and the Acute Hospital Care at Home program also lapsed. Interpretation of imaging studies performed via teleradiology are not affected.

CMS instructed providers that choose to perform telehealth services not payable by Medicare on or after Oct. 1, to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage.

ACR® continues to closely monitor this extremely fluid situation. For more information or if you have questions about the Medicare claims hold or the lapse of Medicare telehealth flexibilities, contact Katie Keysor, ACR Senior Director, Economics and Health Policy.