All Insurance Policy Changes (Page 118)

Continuing from page 117. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Medium impact
[Georgia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, CPT code 81345 (TERT gene analysis for thyroid carcinoma and glioblastoma multiforme) now requires prior authorization/precertification through Carelon Medical Benefits Management for Anthem Blue Cross and Blue Shield Medicare Advantage plans in Georgia. Providers must submit authorization requests via the Carelon provider portal, Availity Essentials, or email before performing this genetic test.
High impact
[New York] Medical Policy and Clinical Guideline updates effective
Anthem BCBS·Effective Oct 1, 2026
Anthem has issued new and revised medical policies and clinical guidelines effective October 1, 2026, affecting coverage determinations for specific procedures including intrabuccal radiofrequency devices for cancer, mucosal integrity testing, Alzheimer's biomarker testing, gene therapy for beta thalassemia, deep brain stimulation, inhaled nitric oxide, and cochlear implants. Previously covered services may now be determined as not medically necessary or investigational, requiring billing teams to verify coverage before claim submission.
High impact
Medical Policy Updates for October 2026
Blue Cross Blue Shield of Massachusetts·Effective Oct 1, 2026
This comprehensive October 1, 2026 policy update affects 13 medical specialties with 30+ policy changes including: Kerecis Omega3 moving from investigational to medically necessary for diabetic ulcers (Policy 663), multiple sclerosis hematopoietic cell transplantation now medically necessary (Policy 192), 8 new infectious disease and specialty lab testing policies with no prior auth required, 2 new investigational digital therapeutics policies (not covered), and retirement of 2 lab policies with code migrations. Most changes require no provider action but billing teams must track code movements and retired policies.
High impact
Maternity Billing Changes for 2027
Highmark·Effective Jan 1, 2027
Effective January 1, 2027, Highmark will implement industry-wide maternity billing changes replacing the current global maternity code with service-level coding across four phases of care (antepartum, labor management, delivery, postpartum). Antepartum and postpartum care will now use standard E/M codes instead of global codes, while new codes will be introduced for labor management, delivery, and specific obstetric procedures. Billing teams must prepare systems and workflows for this transition before the effective date.
Medium impact
Be prepared: Annual federal audit of commercial plans launching soon
UnitedHealthcare·Effective Jul 1, 2026
UnitedHealthcare will begin conducting the HHS Risk Adjustment Data Validation (RADV) audit in July 2026, randomly selecting healthcare providers to submit medical records for UnitedHealthcare commercial members who received care during specific dates in 2025. Practices selected must submit complete, dated, and signed medical records including clinical documentation, diagnostic reports, and patient demographics within the audit timeframe.
Medium impact
Available now: The July 1 Preferred Lab Network roster
UnitedHealthcare·Effective Jul 1, 2026
UnitedHealthcare has updated its Preferred Lab Network roster effective July 1, 2026. The network includes designated laboratories across four service categories (Full test menu, Genetic/molecular pathology, Pathology, and Toxicology). Referring patients to these preferred labs may reduce out-of-pocket costs, and providers will be able to identify them in UnitedHealthcare directories and the Designated Diagnostic Provider tool.
Medium impact
Changed naming convention for commercial UCap Capitation Detail Files
UnitedHealthcare·Identified Jul 2, 2026
Failed to analyze policy change
Low impact
Advance health equity: Hypertension awareness and care
UnitedHealthcare·Identified Jul 2, 2026
UnitedHealthcare issued a chronic disease awareness initiative focused on hypertension management and health equity. This is an informational/educational policy directing providers to prioritize hypertension screening, monitoring, and gap closure using HEDIS CBP measures, with emphasis on addressing social determinants of health (SDOH) barriers. No billing code changes, prior authorization modifications, or coverage alterations are announced.
Medium impact
The Salvation Army – Central Territory members added to Choice Plus network
UnitedHealthcare·Effective Jul 1, 2026
The Salvation Army – Central Territory members are being added to the UnitedHealthcare Choice Plus network effective July 1, 2026. Billing teams must recognize these members by their member ID cards, route claims to the correct address/EDI payer ID (39026), and obtain prior authorization through Chesterfield Resources for all hospital admissions (with 24-hour reporting requirement for emergency admissions).
Medium impact
New drugs added to UnitedHealthcare Individual Exchange Plan prescription drug list
UnitedHealthcare·Effective Jul 1, 2026
UnitedHealthcare is adding three new medications to the prescription drug list for Individual Exchange Plans effective July 1, 2026: Airsupra (no prior authorization), Qulipta (prior authorization and quantity limit required), and Zeposia (prior authorization and quantity limit required). Billing and clinical teams must update their systems to recognize these drugs and implement the appropriate authorization requirements.
High impact
Medicare: New DME process for select members in multiple states
UnitedHealthcare·Effective Sep 1, 2026
Effective September 1, 2026, Synapse Health will manage DME ordering and fulfillment for select UnitedHealthcare Medicare Advantage plans in multiple states. Providers must transition to prescribing through the Synapse Health e-prescribing portal, and DME suppliers must join the Synapse Health network to continue serving UnitedHealthcare members. This change affects Individual HMO/PPO plans, C-SNP, and D-SNP plans in 11 states, with a defined list of covered and non-covered DME categories.
High impact
View updated national Gold Card code list
UnitedHealthcare·Effective May 1, 2026
UnitedHealthcare has updated its national Gold Card code list effective May 1, 2026. Certain procedure codes have been removed from the Gold Card list and will no longer require prior authorization as part of UnitedHealthcare's ongoing prior authorization reduction efforts. This change applies across all UnitedHealthcare commercial plans, Individual Exchange plans, Medicare Advantage plans, and Community Plans.
High impact
Prior authorization required for radiology services for Surest plans
UnitedHealthcare·Effective Oct 1, 2026
Beginning October 1, 2026, Surest (a UnitedHealthcare company) will require prior authorization for four specific outpatient radiology services on fully insured and level funded plans: CT scans, MRI/MRA, nuclear cardiology, and PET scans. Billing teams must obtain prior authorization numbers before scheduling these services and verify coverage decisions before rendering care, or claims will be denied.
Medium impact
New genetic and molecular prior auth program requirements
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare is adding two new AMA genetic and molecular test CPT codes (0648U and 0651U) to their prior authorization requirements, effective October 1, 2026. Billing teams must ensure these codes trigger prior authorization requests before service delivery to avoid claim denials and balance billing restrictions.
Medium impact
Medicaid: Prior authorization removal for select electrical stimulation codes
UnitedHealthcare·Effective Sep 1, 2026
Effective September 1, 2026, UnitedHealthcare Community Plans will remove prior authorization requirements for electrical stimulation codes G0281 and G0282 in seven states. Billing teams must update their systems to stop requiring prior authorization for these codes to avoid unnecessary delays and claim processing issues.
High impact
Ohio Medicaid: Provider enrollment requirement
UnitedHealthcare·Identified Jul 2, 2026
Ohio Medicaid now requires all providers serving Medicaid managed care and OhioRISE members to be enrolled and active in the Provider Network Management (PNM) system before rendering and billing services. Claims from unenrolled providers will be rejected at the EDI front door, not paid, and not accepted as encounters. Providers must verify enrollment status immediately and complete enrollment through one of four available options to avoid claim denials.
Medium impact
Ohio Medicaid: Incontinence and respiratory prior auth requirements
UnitedHealthcare·Identified Jul 2, 2026
Failed to analyze policy change
Medium impact
Ohio Medicaid: Change to doula coordination of benefits
UnitedHealthcare·Effective Jul 1, 2026
Effective July 1, 2026, Ohio Medicaid changes doula services coordination of benefits rules. Commercial insurance plans now cover doula services, requiring Medicaid to be the payer of last resort. UnitedHealthcare Community Plan of Ohio will only pay for doula services after the member's primary commercial insurance pays first.
High impact
New Mexico Medicaid: Requirement to enroll with state delayed to October
UnitedHealthcare·Effective Oct 1, 2026
New Mexico Medicaid has extended the provider enrollment deadline from July 1, 2026 to October 1, 2026. All attending, referring, ordering, and prescribing providers and pharmacists must enroll with the state by this date or have claims denied for services rendered on or after October 1, 2026. Providers must include NPI, TIN, and Payer ID 87748 (87726 for electronic visit verification) on claims.
High impact
Maryland Medicaid: Reminder of state medical records audit
UnitedHealthcare·Effective Aug 1, 2026
Maryland Medicaid is conducting annual encounter data validation audits from August through November 2026, comparing medical records against claims submissions. Billing providers must ensure documentation is complete, accurate, and properly aligned with billed procedure, diagnosis, and revenue codes to avoid audit findings, claim denials, or payment recoupments.
High impact
Maryland Medicaid: Plan ahead for the MPRIME provider enrollment transition
UnitedHealthcare·Effective Oct 1, 2026
Maryland Medicaid is transitioning its provider enrollment system from ePREP to MPRIME in October 2026. Providers must submit pending applications and complete revalidations before temporary hold periods (July 1 for moderate/high-risk providers, August 1 for limited-risk providers), then create new MPRIME accounts and re-associate with existing records when the system goes live. Failure to act could result in enrollment suspension and inability to contract with MCOs.
High impact
Massachusetts Medicaid: Coverage change for weight loss and obesity drugs
UnitedHealthcare·Effective Jul 3, 2026
Effective July 3, 2026, UnitedHealthcare Community Plan of Massachusetts will no longer cover prescription weight loss and obesity drugs for weight loss/obesity indications. However, these same drugs will continue to be covered ONLY when prescribed for Medicare-covered conditions (type 2 diabetes, cardiovascular disease, obstructive sleep apnea, etc.). Billing teams must obtain prior authorization for any weight loss/obesity drug prescribed for non-weight-loss indications to ensure coverage.
High impact
Arizona Medicaid: Vaccines for Children renewal requirement
UnitedHealthcare·Identified Jul 2, 2026
Healthcare providers enrolled in the Arizona Vaccines for Children (VFC) program must renew their enrollment by August 31, 2026. Failure to renew will result in program inactivation for non-compliance, and patients under age 18 may be removed from the provider's patient panel, disrupting vaccine administration services.
Medium impact
Pharmacy and clinical updates
UnitedHealthcare·Identified Jul 2, 2026
Failed to analyze policy change
Medium impact
Specialty Medical Injectable Drug program updates
UnitedHealthcare·Identified Jul 2, 2026
Failed to analyze policy change

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Archive by year

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[Georgia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[New York] Medical Policy and Clinical Guideline updates effective

Medical Policy Updates for October 2026

Maternity Billing Changes for 2027

Be prepared: Annual federal audit of commercial plans launching soon

Available now: The July 1 Preferred Lab Network roster

Changed naming convention for commercial UCap Capitation Detail Files

Advance health equity: Hypertension awareness and care

The Salvation Army – Central Territory members added to Choice Plus network

New drugs added to UnitedHealthcare Individual Exchange Plan prescription drug list

Medicare: New DME process for select members in multiple states

View updated national Gold Card code list

Prior authorization required for radiology services for Surest plans

New genetic and molecular prior auth program requirements

Medicaid: Prior authorization removal for select electrical stimulation codes

Ohio Medicaid: Provider enrollment requirement

Ohio Medicaid: Incontinence and respiratory prior auth requirements

Ohio Medicaid: Change to doula coordination of benefits

New Mexico Medicaid: Requirement to enroll with state delayed to October

Maryland Medicaid: Reminder of state medical records audit

Maryland Medicaid: Plan ahead for the MPRIME provider enrollment transition

Massachusetts Medicaid: Coverage change for weight loss and obesity drugs

Arizona Medicaid: Vaccines for Children renewal requirement

Pharmacy and clinical updates

Specialty Medical Injectable Drug program updates