All Insurance Policy Changes (Page 11)

Continuing from page 10. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
26-1058 Provider Communication Posted Online and Operations Manual Updates for August 2026
Health Net·Effective Aug 31, 2026
Health Net California published multiple operational manual updates effective August 2026, with the most critical change being an update to 'Services Not Requiring Prior Authorization' (effective 8/31/26) that clarifies prior authorization exemptions for select hospice, behavioral health, maternal health, and preventive services. Additional updates address cognitive health assessment training removal, Medi-Cal prohibited entity payment guidelines, and member protections regarding public benefit form fees.
High impact
26-1059 Provider Communication Posted Online and Operations Manual Updates for August 2026
Health Net·Effective Aug 31, 2026
This August 2026 policy update includes multiple operational changes affecting Medi-Cal providers in Fresno, Kings, and Madera counties. Key changes include: removal of cognitive health assessment training requirements (effective 8/4/26), updated claims payment guidelines for prohibited entities (effective 8/11/26), new guidance prohibiting member charges for public benefit forms (effective 8/21/26), and clarification of services not requiring prior authorization including hospice, behavioral health, maternal health, and preventive services (effective 8/31/26).
High impact
MA08.088f, Ocrelizumab (Ocrevus®) and Ocrelizumab and Hyaluronidase-ocsq (Ocrevus Zunovo®)
Independence Blue Cross·Effective Sep 7, 2026
This is a 1-day-old policy update for Ocrelizumab (Ocrevus®) and Ocrelizumab with Hyaluronidase (Ocrevus Zunovo®) affecting Medicare Advantage plans. The policy modifies medical necessity criteria for these drugs, effective 09/07/2026. Without access to the full policy text details, the billing team must immediately obtain and review the complete criteria to determine impact on prior authorization requirements, documentation standards, and claims processing.
High impact
08.01.38f, Ocrelizumab (Ocrevus®) and Ocrelizumab and Hyaluronidase-ocsq (Ocrevus Zunovo®)
Independence Blue Cross·Effective Sep 7, 2026
Policy 08.01.38f updates medical necessity criteria for Ocrelizumab (Ocrevus®) and Ocrelizumab and Hyaluronidase-ocsq (Ocrevus Zunovo®). The policy became effective on 09/07/2026 and was posted on 09/08/2026. Specific details of the criteria changes are not provided in the source material, requiring immediate review of the full policy document.
Medium impact
09.00.58b, Coronary Artery Calcium (CAC) Testing Using Computed Tomography (Independence Administrators)
Independence Blue Cross·Effective Sep 19, 2026
Independence Administrators has updated medical necessity criteria for Coronary Artery Calcium (CAC) Testing Using Computed Tomography (Policy 09.00.58b). This is a fresh policy change effective 09/19/2026 that may impact coverage decisions, prior authorization requirements, or documentation standards for CAC screening procedures. The specific criteria changes are not detailed in the provided policy header, requiring immediate review of the full policy text to determine billing and clinical workflow impacts.
High impact
Metabolic monitoring for patients on antipsychotic medications
Harvard Pilgrim Health Care·Identified Sep 8, 2026
Point32Health issued a metabolic monitoring policy for patients on antipsychotic medications, emphasizing annual screening for diabetes and cholesterol levels. The policy provides approved CPT codes for billing glucose, HbA1c, LDL-C, and other cholesterol tests, and requires providers to document baseline metabolic testing at discharge and coordinate care across behavioral health, primary care, and prescribing providers.
Low impact
The importance of culturally appropriate health care
Harvard Pilgrim Health Care·Identified Sep 7, 2026
Point32Health issued a provider guidance newsletter emphasizing culturally appropriate care practices and available interpretation services for non-English-speaking patients. This is an informational policy outlining best practices and resources rather than a billing or coverage change.
High impact
Reminder: US Family Health Plan transition
Harvard Pilgrim Health Care·Effective Jan 1, 2027
US Family Health Plan (USFHP) administrative operations are transitioning from Tufts Health Plan to BrightonOne effective January 1, 2027. Claims processing will transfer to Signature Performance, and providers must establish direct contracts with BrightonOne before the 2027 plan year to remain in-network. The billing team must verify contract status and ensure proper credentialing to avoid service interruptions.
High impact
Nursing Facility Quality Assessment Methodology Change
Maryland Medicaid·Effective Jul 1, 2025
Maryland Medicaid is transitioning nursing facility quality assessment (QA) rates from a non-uniform structure to a uniform percentage model effective July 1, 2025, to comply with new federal Medicaid waiver requirements. For FY 2026, QA rates are adjusted by 0.8%, changing the standard rate from $32.92 to $32.94 per diem, while the rate for the five highest-volume Medicaid facilities decreases from $3.04 to $2.70. Facilities must reconcile Q1-Q3 FY 2026 payments using revised rates, with reconciliation occurring in the Q4 Cognito form due August 29, 2026.
Medium impact
Updated Dispute Resolution Process
Maryland Medicaid·Effective Oct 1, 2026
Maryland's Dispute Resolution Committee (DRC) process for behavioral health claims is shifting from postal mail to electronic submission only, effective October 1, 2026. All DRC submissions must now go to mdh.mcoasodisputeresolution@maryland.gov via secure email. The policy also clarifies eligibility requirements: only claims denied by both the BHASO and MCO, after first-level appeals with both payers, and with no prior payment except EMTALA triage fees, can be submitted to the DRC.
Medium impact
Coverage of Imcivree for Monogenic or Syndromic Obesity
Maryland Medicaid·Effective Apr 1, 2024
Maryland Medicaid is reminding providers that Imcivree coverage for monogenic or syndromic obesity has been in effect since April 1, 2024. This transmittal clarifies FDA-approved indications (acquired hypothalamic obesity, Bardet-Biedl syndrome, and POMC/PCSK1/LEPR deficiency) and specifies billing codes: NDC for FFS programs and HCPCS J3490 for MCO medical benefits.
High impact
Prenatal Care and New Obstetric Billing Codes Seminar
Blue Cross Blue Shield of Vermont·Effective Sep 1, 2026
Blue Cross VT is transitioning obstetric billing from global codes (59425, 59426) to new unbundled maternity services codes effective 2027. Beginning September 1, 2026, prenatal care must be billed using E/M codes with modifier -TH and Z34A ICD-10 codes for gestation confirmation. A mandatory webinar on September 16, 2026, will cover implementation details, clinical guidance, and workflow changes required for this significant coding transition.
Medium impact
Carelon Routine Maintenance
Blue Cross Blue Shield of Vermont·Effective Sep 11, 2026
Blue Cross VT's radiology management partner Carelon will have scheduled maintenance windows when their prior authorization tool will be unavailable. Providers must use an alternative contact method (phone to Care Management) for urgent prior authorization requests during these blackout periods: September 11-13, 2026 and October 9-11, 2026.
Medium impact
Concert Genetics Policy CG.PP.551A
Ambetter·Effective Oct 1, 2026
Ambetter Health is implementing a new genetic testing payment policy (CG.PP.551A) effective October 1, 2026, requiring Concert Genetics' unique test identifier (GTU) on all genetic testing claims for the Concert QAI program. Labs must ensure GTU identifiers are included on claims to avoid editing or denial, though pre-registration with Concert is not mandatory.
High impact
Provider Alert: Payment Platform Transition from Payspan to Zelis
Ambetter·Effective Nov 6, 2026
Effective November 2026, provider claim payments and remittance information will transition from Payspan to the Zelis payment platform. This is a payment delivery and access change only—reimbursement rates, claims adjudication, and payment methodology remain unchanged. The billing team must verify current payment setup, confirm electronic payment methods, and coordinate enrollment before staggered conversion dates by line of business.
High impact
2026 Medicare Advantage Formulary Updates
Highmark·Effective Jan 1, 2026
Highmark is updating its Medicare Part D formularies effective January 1, 2026, with some medications being removed or having new restrictions. Providers and members will receive notification letters starting mid-November 2025. Billing teams must be prepared to handle formulary changes, submit coverage determination requests starting November 17, 2025, or identify covered alternatives for affected medications.
High impact
Billing updates effective Nov. 1, 2026
Harvard Pilgrim Health Care·Effective Nov 1, 2026
Effective Nov. 1, 2026, Tufts Health Direct will deny reimbursement for CPT code 99459 (pelvic exam add-on) and CPT codes 76376 and 76377 (3D rendering with interpretation) when billed, as these services are now considered integral to primary procedure codes. Modifier usage will not override these denials.
Medium impact
Cosmetic and Reconstructive Surgery - Medicare Advantage (Revised)
Humana·Effective Mar 2, 2026
This is a revised Medicare Advantage policy (effective 03/02/2026) on cosmetic and reconstructive surgery coverage that consolidates national coverage rules and references applicable MAC Local Coverage Determinations by geographic jurisdiction. The policy clarifies which procedures are covered (reconstructive only, with specific functional impairment criteria), which require medical necessity documentation, and directs billing teams to apply jurisdiction-specific LCDs for benign skin lesion removal, panniculectomy, rhinoplasty/septoplasty, and other procedures. Key update: Hair removal (CPT 17380) is now restricted to recurrent pilonidal cyst cases only.
High impact
Medicaid Reminder: Know When To Request Post Acute Care Authorizations
BCBS Illinois·Identified Sep 5, 2026
Blue Cross Community Health Plans (BCCHP) Medicaid now requires providers to request prior authorization for post-acute care facility admissions no more than three days prior to admission, rather than earlier timeframes. This change reflects the plan's requirement to account for rapidly changing health conditions and medical necessity. Billing teams must update their prior authorization submission workflows to align with this three-day window.
Medium impact
2026.47 - Provider Bulletin - Familial Chylomicronemia Syndrome (FCS) Agents Redemplo and Tryngolza
Connecticut Medicaid (HUSKY Health)·Effective Oct 1, 2026
Connecticut DSS is implementing new clinical criteria and Prior Authorization (PA) requirements for two Familial Chylomicronemia Syndrome (FCS) agents: Redemplo and Tryngolza, effective October 1, 2026. All pharmacy claims for these drugs under HUSKY A, HUSKY C, HUSKY D, and Emergency Medicaid Dialysis Services will require PA submission, with claims denied if any PA criteria questions are answered NO.
High impact
2026.48 - Provider Bulletin - Addition of the HIV/AIDS Class to the Preferred Drug List (PDL)
Connecticut Medicaid (HUSKY Health)·Effective Oct 1, 2026
Connecticut Medicaid is adding the HIV/AIDS drug class to its Preferred Drug List (PDL) effective October 1, 2026. Non-preferred HIV/AIDS medications will require prior authorization (PA). Pharmacies must proactively switch patients to preferred alternatives or obtain PA before dispensing non-preferred products. Brand name preferred products can be dispensed without DAW code '1' unless medically necessary documentation is provided.
High impact
2026.49 - Provider Bulletin - Updates to the Diabetic Supply Preferred Product List for Pharmacy Claims
Connecticut Medicaid (HUSKY Health)·Effective Oct 1, 2026
Connecticut Medicaid is updating the Preferred Diabetic Supply Product List (PDSPL) effective October 1, 2026. Pharmacies must dispense only preferred NDCs listed on the updated PDSPL and submit claims with those specific NDCs via POS in NCPDP D.0 format. Claims submitted with non-preferred NDCs will be denied.
High impact
DSS Important Message - System Downtime Date Change Notification
Connecticut Medicaid (HUSKY Health)·Effective Sep 6, 2026
The Connecticut Medical Assistance Program (CMAP) has rescheduled its system maintenance downtime from September 13, 2026 (second Sunday) to September 6, 2026. During the 12:00 a.m. to 8:10 a.m. maintenance window on September 6, providers will be unable to access pharmacy POS, eligibility verification, provider web functions, and transaction systems. Providers must plan and complete transactions outside this window to avoid service disruptions.
High impact
DSS Important Message - Multi-Factor Authentication (MFA) Is Mandated Effective August 1, 2026, Open Office Hours for Multi-Factor Authentication/Security Questions
Connecticut Medicaid (HUSKY Health)·Effective Aug 1, 2026
The Connecticut Medical Assistance Program (CMAP) is mandating Multi-Factor Authentication (MFA) for all providers, trading partners, and drug labelers accessing the secure Web Portal, effective August 1, 2026. Starting immediately, users can enroll in MFA using either an Authenticator App or Email Verification. After August 1, 2026, MFA enrollment will be required (no longer optional) for all Master Users and Clerks to log in, reset passwords, and update electronic fund transfer information.
High impact
Prior Authorization Submission Changes (Effective October 1)
Blue Cross Blue Shield of Wyoming·Effective Oct 1, 2026
Effective October 1, 2026, Wyoming providers must submit all initial prior authorization and concurrent review requests through Availity instead of fax. The previous fax number (307-778-8582) will no longer be accepted. Wyoming providers must continue submitting discharge notifications by fax to 307-432-2917. Out-of-state providers associated with specified facility types are encouraged to use Availity but may fax to 307-432-2917 if unable. Pharmacy prior authorizations continue via fax.

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26-1058 Provider Communication Posted Online and Operations Manual Updates for August 2026

26-1059 Provider Communication Posted Online and Operations Manual Updates for August 2026

MA08.088f, Ocrelizumab (Ocrevus®) and Ocrelizumab and Hyaluronidase-ocsq (Ocrevus Zunovo®)

08.01.38f, Ocrelizumab (Ocrevus®) and Ocrelizumab and Hyaluronidase-ocsq (Ocrevus Zunovo®)

09.00.58b, Coronary Artery Calcium (CAC) Testing Using Computed Tomography (Independence Administrators)

Metabolic monitoring for patients on antipsychotic medications

The importance of culturally appropriate health care

Reminder: US Family Health Plan transition

Nursing Facility Quality Assessment Methodology Change

Updated Dispute Resolution Process

Coverage of Imcivree for Monogenic or Syndromic Obesity

Prenatal Care and New Obstetric Billing Codes Seminar

Carelon Routine Maintenance

Concert Genetics Policy CG.PP.551A

Provider Alert: Payment Platform Transition from Payspan to Zelis

2026 Medicare Advantage Formulary Updates

Billing updates effective Nov. 1, 2026

Cosmetic and Reconstructive Surgery - Medicare Advantage (Revised)

Medicaid Reminder: Know When To Request Post Acute Care Authorizations

2026.47 - Provider Bulletin - Familial Chylomicronemia Syndrome (FCS) Agents Redemplo and Tryngolza

2026.48 - Provider Bulletin - Addition of the HIV/AIDS Class to the Preferred Drug List (PDL)

2026.49 - Provider Bulletin - Updates to the Diabetic Supply Preferred Product List for Pharmacy Claims

DSS Important Message - System Downtime Date Change Notification

DSS Important Message - Multi-Factor Authentication (MFA) Is Mandated Effective August 1, 2026, Open Office Hours for Multi-Factor Authentication/Security Questions

Prior Authorization Submission Changes (Effective October 1)