All Insurance Policy Changes (Page 12)

Continuing from page 11. 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
5160-2-22 - Non-DRG prospective payment for hospital services. (Amend/Original File)
Ohio Medicaid·Effective Oct 5, 2026
Ohio Medicaid has filed an amendment to Rule 5160-2-22 regarding Non-DRG prospective payment for hospital services. This is a regulatory filing currently in the original file stage with an effective date of October 5, 2026. The specific policy details are not provided in the source material, requiring review of the full rule body and supporting documents to determine billing impact.
High impact
Medical Policy Updates Effective 11/15/2026
Blue Cross Blue Shield of Nebraska·Effective Nov 15, 2026
Blue Cross Blue Shield of Nebraska implemented two major medical policy updates effective 11/15/2026: (1) New quantity limits capping Physical Therapy, Occupational Therapy, and Speech Therapy at 25 hours per week each, and (2) Revised autism spectrum disorder coverage requiring prior authorization with stricter documentation, assessment, and progress criteria for ABA services. Both policies establish new preauthorization and documentation requirements that will impact claim processing and provider billing workflows.
Medium impact
EFT Payments Delayed Due to Labor Day Bank Holiday
Texas Medicaid·Effective Sep 7, 2026
Electronic funds transfer (EFT) payments from TMHP will be delayed by one business day due to the Labor Day bank holiday on September 7, 2026. Providers should expect payments by Monday, September 14, 2026, instead of the originally scheduled date of September 7, 2026.
Medium impact
Cranial Remolding Orthosis eLearning Now Available
Texas Medicaid·Effective Sep 1, 2026
Texas Medicaid (TMHP) has released mandatory eLearning training for cranial remolding orthosis (CRO) benefits, covering eligibility requirements, authorization, and reimbursement updates that became effective September 1, 2026 under House Bill 426. Billing staff must complete this training to properly process CRO claims and understand new benefit policy requirements.
Low impact
Abuse, Neglect and Exploitation: Prevention and Response in Intermediate Care Facilities In-Person Training
Texas Medicaid·Identified Sep 5, 2026
HHSC Long-Term Care Regulation is offering a voluntary in-person training on September 8, 2026, in Lubbock, TX for ICF staff on abuse, neglect, and exploitation (ANE) prevention and response. The training awards continuing education credits for RNs, social workers, facility administrators, and nurse aides, but does not change billing codes, coverage policies, or reimbursement requirements.
High impact
Dental Office Reference Manual – Reissue; Exhibits A-C Dental Benefits Covered Coding Updates
Illinois Medicaid - HFS·Identified Sep 5, 2026
Illinois Department of Financial and Professional Regulation has reissued the Dental Office Reference Manual (DORM) with updates to dental benefits covered coding. Providers must review the updated DORM and Exhibits A-C for coding changes to ensure accurate billing and payment from the Department.
Medium impact
26-1099 Health Net to Exit California Commercial Group Business Starting February 28, 2027
Health Net·Effective Feb 28, 2027
Health Net is discontinuing its Commercial Group health plans in California, with coverage ending starting February 28, 2027, though some employer groups may retain coverage longer based on individual contracts. Existing coverage, provider participation, and billing processes remain unchanged at this time, but the billing team must monitor future communications for claims submission, authorization, and payment runout procedures that will be detailed as the transition approaches.
High impact
Upcoming Changes for Noncitizen Member Eligibility
Wisconsin Medicaid (ForwardHealth)·Effective Oct 1, 2026
Effective October 1, 2026, Wisconsin Medicaid will restrict eligibility for noncitizen adults to only U.S. citizens, nationals, lawful permanent residents, Cuban-Haitian entrants, and Compact of Free Association citizens. Adults with statuses like refugees, asylees, parolees, trafficking victims, and VAWA self-petitioners will lose coverage. Children under 19, pregnant individuals, and young adults under 21 in mental health institutions remain eligible. Providers must verify member eligibility before delivering services to avoid claim denials.
Medium impact
MA08.090i, Lanreotide (Somatuline Depot)
Independence Blue Cross·Effective Sep 4, 2026
Policy MA08.090i for Lanreotide (Somatuline Depot) has been updated with changes to medical necessity criteria and medical coding requirements, effective 09/04/2026. The billing team must review the full policy text to identify specific coding and prior authorization updates for this injectable somatostatin analog.
Medium impact
MA00.002t, Continuous Glucose Monitors and Home Blood Glucose Monitors and Supplies
Independence Blue Cross·Effective Oct 5, 2026
Policy MA00.002t regarding Continuous Glucose Monitors and Home Blood Glucose Monitors and Supplies has been updated. This is a coverage and/or reimbursement position change with general description, guidelines, or informational updates. The billing team must review the full policy text to identify specific coverage criteria, billing code changes, or reimbursement adjustments effective October 5, 2026.
Medium impact
08.01.52h, Mogamulizumab-kpkc (Poteligeo)
Independence Blue Cross·Effective Sep 4, 2026
Policy 08.01.52h for Mogamulizumab-kpkc (Poteligeo) has been updated effective 09/04/2026 with changes to medical necessity criteria and medical coding requirements. The billing team must review updated documentation and coding standards for this specialty pharmacy drug to ensure compliant claim submission.
Medium impact
Permanently Implanted Prostatic Devices for Benign Prostatic Hyperplasia
Blue Cross & Blue Shield of Mississippi·Identified Sep 5, 2026
This new policy classifies permanently implanted prostatic stent devices (ProVee System and Zenflow Spring Implant)—both recently FDA-approved in December 2025—as investigational for treating lower urinary tract symptoms due to benign prostatic hyperplasia. Billing teams must deny claims for these procedures as not medically necessary, except for Federal Employee Program (FEP) members where coverage may apply based on medical necessity alone.
High impact
CMS Telehealth Billing Change for RHCs and FQHCs Preheader: Effective Oct. 1 for MA members
Blue Cross Blue Shield of Kansas·Effective Oct 1, 2026
Effective October 1, 2026, CMS is discontinuing the use of HCPCS code G2025 for distant-site telehealth services billed by RHCs and FQHCs to Medicare Advantage members. Billing teams must transition to submitting the appropriate CPT or HCPCS code describing the actual service furnished, along with the applicable telehealth modifier and revenue code.
Low impact
BCBSKS closed for Labor Day
Blue Cross Blue Shield of Kansas·Identified Sep 5, 2026
Blue Cross and Blue Shield of Kansas (BCBSKS) will be closed on Monday, September 7 for Labor Day. Weekly claims will be released early on Friday, September 4, but payment days will remain unchanged. No changes to billing processes or claim submission requirements are needed.
High impact
Pharmacy Medical Policy Updates
Blue Cross Blue Shield of Kansas·Effective Oct 1, 2026
Blue Cross Blue Shield Kansas updated pharmacy medical policy for 40+ prescription drugs and biologic agents across two programs (Prescription Drug Policies and Medical Pharmacy Solutions Program Policies). These updates take effect October 1, 2026, with three medications effective November 1, 2026. Billing teams must verify prior authorization requirements and formulary status for all affected medications before the effective date.
Medium impact
Justice-Involved (JI) Reentry Initiative: Trainings Scheduled for September through November 2026
Medi-Cal·Identified Sep 4, 2026
Medi-Cal is offering mandatory training webinars for providers participating in the Justice-Involved (JI) Reentry Initiative, with sessions scheduled September through November 2026 covering embedded provider billing, behavioral health services, screening portals, and claims submission methods. Providers must register through the Medi-Cal Learning Portal to attend their selected session.
High impact
July Town Hall FAQ
Alaska Medicaid·Identified Sep 4, 2026
Alaska Medicaid clarifies Third Party Liability (TPL) billing procedures for providers ineligible for Medicare enrollment, particularly behavioral health providers. Providers unable to enroll in Medicare must now submit proof of ineligibility with claims using attachment code 'EB' on the 837 form and include the Attachment Cover Sheet. Claims for dual-eligible recipients must bill Medicare first; Medicaid pays as secondary only after Medicare processes the claim and issues an EOB.
Medium impact
August Town Hall FAQ
Alaska Medicaid·Identified Sep 4, 2026
Alaska Medicaid released clarifications on provider enrollment, claims billing, and administrative procedures through an August 19, 2026 Town Hall FAQ. Key updates include: (1) enrollment forms accept digital or manual signatures; (2) multiple provider updates should be submitted one email per Provider ID; (3) dual-eligible patients with Medicare non-coverage can be billed directly with proof of non-coverage; (4) behavioral health providers can request specific claims via DBH email; (5) tribal billing manual feedback deadline is mid-September 2026 for October updates; (6) inactive Organization Administrator accounts require a Change Request form to reactivate.
High impact
[California] Medi-Cal members may not be charged for forms or for providing information
Anthem BCBS·Identified Sep 4, 2026
Effective immediately, Medi-Cal providers are prohibited from charging patients any fees for completing forms or providing information related to public benefit program eligibility claims or appeals. This applies to all Medi-Cal members and their representatives. Providers may continue charging for medical record copies (up to $0.25/page for paper, $0.50/page for microfilm, and reasonable fees for diagnostic films).
High impact
[New York] Precertification/prior authorization list change notification
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Blue Cross and Blue Shield in New York is adding 60 wound healing/soft tissue grafting product codes and 1 prostate cancer screening biomarker code to its precertification/prior authorization requirements. All services under these criteria must receive prior authorization before delivery to avoid claim denial.
Medium impact
[Ohio] General and LTSS provider orientations for Anthem MyCare Ohio
Anthem BCBS·Identified Sep 4, 2026
Anthem MyCare Ohio is offering mandatory provider orientations for the Next Generation MyCare Ohio program, with separate sessions for general providers, LTSS agency providers, and LTSS independent providers. All Ohio providers must attend the appropriate orientation session to understand program requirements, processes, and support tools for serving MyCare Ohio members effectively.
Low impact
Ambetter of North Carolina Inc. Provider Insights
Ambetter·Identified Sep 4, 2026
Ambetter of North Carolina Inc. is launching a new quarterly Provider Insights webinar series to educate providers on clinical topics and plan updates. The inaugural session on September 22, 2026 will feature virtual speech therapy education. This is an informational announcement about an educational initiative, not a billing or coverage policy change.
Medium impact
New in Availity Essentials: Streamline Authorization Follow-Ups by Viewing and Responding to RFAI Online
Ambetter·Identified Sep 4, 2026
Availity Essentials now allows providers to view and respond to Requests for Additional Information (RFAI) directly within the platform instead of through phone calls or faxes. This streamlines the prior authorization follow-up process by enabling online submission of supporting clinical documentation through a centralized dashboard.
Medium impact
New in Availity Essentials: Streamline Authorization Follow-Ups by Viewing and Responding to RFAI Online
Ambetter·Identified Sep 4, 2026
Availity Essentials now allows providers to view and respond to Requests for Additional Information (RFAI) directly within the platform instead of via phone or fax. This streamlines the prior authorization follow-up process by enabling secure online submission of supporting clinical documentation through a centralized Authorization/Referral Dashboard.
Medium impact
New in Availity Essentials: Streamline Authorization Follow-Ups by Viewing and Responding to RFAI Online
Ambetter·Identified Sep 4, 2026
Availity Essentials now enables providers to view and respond to requests for additional information (RFAI) directly within the platform, eliminating the need for phone calls and faxes. This streamlines the prior authorization follow-up process by allowing secure online submission of supporting clinical documentation through a centralized dashboard.

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Archive by year

2023 2024 2025 2026

5160-2-22 - Non-DRG prospective payment for hospital services. (Amend/Original File)

Medical Policy Updates Effective 11/15/2026

EFT Payments Delayed Due to Labor Day Bank Holiday

Cranial Remolding Orthosis eLearning Now Available

Abuse, Neglect and Exploitation: Prevention and Response in Intermediate Care Facilities In-Person Training

Dental Office Reference Manual – Reissue; Exhibits A-C Dental Benefits Covered Coding Updates

26-1099 Health Net to Exit California Commercial Group Business Starting February 28, 2027

Upcoming Changes for Noncitizen Member Eligibility

MA08.090i, Lanreotide (Somatuline Depot)

MA00.002t, Continuous Glucose Monitors and Home Blood Glucose Monitors and Supplies

08.01.52h, Mogamulizumab-kpkc (Poteligeo)

Permanently Implanted Prostatic Devices for Benign Prostatic Hyperplasia

CMS Telehealth Billing Change for RHCs and FQHCs Preheader: Effective Oct. 1 for MA members

BCBSKS closed for Labor Day

Pharmacy Medical Policy Updates

Justice-Involved (JI) Reentry Initiative: Trainings Scheduled for September through November 2026

July Town Hall FAQ

August Town Hall FAQ

[California] Medi-Cal members may not be charged for forms or for providing information

[New York] Precertification/prior authorization list change notification

[Ohio] General and LTSS provider orientations for Anthem MyCare Ohio

Ambetter of North Carolina Inc. Provider Insights

New in Availity Essentials: Streamline Authorization Follow-Ups by Viewing and Responding to RFAI Online

New in Availity Essentials: Streamline Authorization Follow-Ups by Viewing and Responding to RFAI Online

New in Availity Essentials: Streamline Authorization Follow-Ups by Viewing and Responding to RFAI Online