All Insurance Policy Changes (Page 127)

Continuing from page 126. 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
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross and Blue Shield (including HealthKeepers, Inc.) now requires prior authorization/precertification for CPT code 0600U (infectious disease wound infection genetic testing with organism and antibiotic resistance identification) for all Virginia PPO and HMO commercial plans. Providers must submit authorization requests through Carelon Medical Benefits Management before performing this test.
High impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Carelon Medical Benefits Management is adding new prior authorization requirements for specific cardiology catheterization procedures (CPT codes C7517, C7552, C7553) and one radiation oncology code (S8030) for Anthem Blue Cross and Blue Shield Medicare Advantage FIDE plans in Virginia. Billing teams must implement prior authorization checks for these codes before the effective date to avoid claim denials.
Medium impact
[Virginia] Clinical Criteria updates (July 2026 Newsletter)
Anthem BCBS·Effective Jul 23, 2026
Anthem Virginia has issued clinical criteria updates effective on multiple dates in July and August 2026 for both Medicare Advantage and Medicaid plans. The bulletin announces guideline updates but does not provide specific clinical criteria details, billing codes, or policy changes in the provided excerpt.
Medium impact
[Virginia] Specialty pharmacy updates (July 2026 Newsletter)
Anthem BCBS·Effective Oct 1, 2026
Anthem Blue Cross and Blue Shield (Virginia) has issued specialty pharmacy updates effective October 1, 2026. However, the actual policy content is not provided in the source material—only headers and publication dates are visible. The billing team cannot implement changes without access to the full policy details specifying which drugs, prior authorization requirements, or reimbursement changes are affected.
Medium impact
[Virginia] Medication safety alerts: reducing opioid and anticholinergic risk
Anthem BCBS·Effective Jun 30, 2026
Anthem Blue Cross has issued a medication safety alert for Medicare Advantage plans in Virginia focusing on reducing opioid and anticholinergic risks. The policy highlights two high-risk medication combinations—opioid/benzodiazepine overlap and multiple anticholinergics in older adults—that align with CMS Part D Star Measures. Providers must implement medication reconciliation, deprescribing protocols, and use of PDMP checks to reduce overdose and fall-related harm.
High impact
[Virginia] Provider data attestation
Anthem BCBS·Effective Jan 1, 2026
Virginia providers contracted with Anthem must verify and update their demographic data every 90 days using the Provider Data Management (PDM) feature in Availity Essentials. Failure to comply will result in removal from the online provider directory and suppression from the FindCare tool effective January 1, 2026 for Commercial plans. Medicaid providers must update data through the DMAS Provider Services Solutions (PRSS) website instead.
High impact
[Virginia] Reminder: provider data attestation
Anthem BCBS·Identified Jul 1, 2026
Anthem Blue Cross and Blue Shield (Virginia) requires all contracted providers to verify and attest to their demographic data every 90 days using the Provider Data Management (PDM) feature in Availity Essentials. Failure to complete attestation within 90 days will result in removal from the online provider directory and classification as non-compliant, which impacts member access and claims processing.
High impact
[Georgia] Clinical Criteria updates
Anthem BCBS·Effective Jul 23, 2026
Anthem Blue Cross Blue Shield (Georgia) has revised 27 clinical criteria policies for specialty drugs covered under Medicare Advantage medical benefits, effective July 23, 2026. These revisions update medical necessity requirements for high-cost biologics, immunoglobulins, and rare disease treatments. Billing teams must review updated clinical criteria before claims submission to ensure compliance with new medical necessity edits.
Medium impact
[Georgia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross and Blue Shield in Georgia is adding CPT code 0600U (infectious disease wound infection testing) to the list of services requiring precertification/prior authorization through Carelon Medical Benefits Management. Providers must obtain prior authorization before performing this genetic/molecular testing or claims will be denied.
Medium impact
[Georgia] Specialty pharmacy updates (July 2026 Newsletter)
Anthem BCBS·Effective Oct 1, 2026
Anthem Blue Cross Blue Shield (Georgia) has issued specialty pharmacy updates effective October 1, 2026. However, the provided policy document contains only header and navigation information without specific policy details, billing codes, coverage changes, or clinical guidance. The actual content of the July 2026 specialty pharmacy updates is not included in the source material.
Medium impact
[Georgia] Medication safety alerts: reducing opioid and anticholinergic risk
Anthem BCBS·Effective Jun 30, 2026
Anthem Blue Cross Blue Shield Georgia is implementing medication safety quality measures focused on reducing opioid-benzodiazepine overlap (COB) and anticholinergic polypharmacy in older adults. This policy requires providers to actively monitor, reassess, and deprescribe high-risk medication combinations to align with CMS Part D Star Measures, with emphasis on medication reconciliation at every visit and transition of care.
High impact
[Georgia] Reminder: provider data attestation
Anthem BCBS·Identified Jul 1, 2026
Anthem Blue Cross Blue Shield of Georgia is reminding contracted providers that they must verify and update their demographic data every 90 days using the Provider Data Management (PDM) feature in Availity Essentials. Failure to complete this attestation requirement can result in removal from the online provider directory and non-compliance status.
Medium impact
Certified Lactation Consultants Eligible to Provide Breastfeeding Instruction Sessions
Nebraska Medicaid·Effective Jul 1, 2026
Effective July 1, 2026, Nebraska Medicaid now recognizes certified lactation consultants (CLCs) as an allowable provider type for breastfeeding instruction sessions (code S9443) under the Prenatal Plus Program, in addition to licensed medical nutrition therapists and international board-certified lactation consultants. This service is limited to once per pregnancy.
High impact
Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600540 - 07/2026)
Colorado Medicaid·Effective Jul 1, 2026
Health First Colorado (Colorado Medicaid) issued a comprehensive July 2026 bulletin with multiple operational and reimbursement changes. Key updates include: (1) a 2% across-the-board rate reduction effective July 1, 2026 for most services except managed care, pharmacy, RHCs, FQHCs, and certain pediatric/maternity services; (2) rate correction for Family Planning modifier services retroactive to April 1, 2026; (3) new claim submission limits (50 detail lines max in Provider Web Portal); (4) new supportive services edits and procedure code restrictions; and (5) multiple operational changes affecting behavioral health, HCBS services, transportation, and other provider types.
High impact
Durable Medical Equipment (DME) Program Wheelchair Diagnosis Documentation Requirements for Nursing Home Participants
Missouri Medicaid (MO HealthNet)·Effective Jun 30, 2026
Missouri's DME program has implemented new wheelchair diagnosis documentation requirements specifically for nursing home participants. Providers must now ensure detailed diagnosis documentation is included with all wheelchair claims for this population, or claims will be denied.
High impact
Upcoming Changes to the MO HealthNet Fee Schedule
Missouri Medicaid (MO HealthNet)·Effective Jun 30, 2026
MO HealthNet has released an updated fee schedule effective 06/30/2026. This is a state Medicaid reimbursement rate change that will affect all Missouri providers billing to MO HealthNet. The billing team must obtain and implement the new fee schedule in their billing system to ensure accurate claim submission and reimbursement.
Medium impact
Updated Hospice Services Billing Guide
Washington Apple Health·Effective May 21, 2026
The Washington State Health Care Authority (HCA) has restored the definition of 'brief period' to the Updated Hospice Services Billing Guide after it was inadvertently removed from the previous edition. 'Brief period' is defined as six days or less within a 30-consecutive-day period. Hospice providers billing Apple Health (Medicaid) in Washington must ensure their billing practices align with this restored definition, which is also codified in WAC 182-551-1010.
High impact
Quarterly Billing Guide Updates, Effective 7/1/2026
Washington Apple Health·Effective Jul 1, 2026
Washington State HCA is publishing quarterly updates to Apple Health (Medicaid) billing guides effective July 1, 2026, with significant changes to vaccine/toxoid (immunization) coverage policy aligned with ESHB 2242 and Washington State Department of Health recommendations. Billing teams must review updated guides for their specific programs to identify coverage and coding changes for immunization services.
Medium impact
COVID-19 testing—Molecular and antigen updates eff. 10/1/2026
Washington Apple Health·Effective Oct 1, 2026
The Washington State Health Care Authority (HCA) has updated the COVID-19 molecular and antigen testing section of the Physician-Related Services/Health Care Professional Services Billing Guide effective October 1, 2026, with added information on client immunodeficiency. Billing teams must review the updated guide to identify specific changes to testing codes and policies, particularly related to immunodeficient patients.
Medium impact
Prior Authorization Required for Select Codes Starting October 1, 2026
Healthfirst·Identified Jul 1, 2026
Failed to analyze policy change
High impact
Prior Authorization Required for Newly Released Codes Starting July 1, 2026
Healthfirst·Effective Jul 1, 2026
Starting July 1, 2026, newly released AMA codes will require prior authorization. The policy references a list of new codes with prior authorization requirements, but specific codes are not detailed in the provided policy summary. Billing teams must identify which new codes apply to their practice and implement prior authorization workflows before the effective date.
Low impact
Healthy Connections Medicaid Provider Training Opportunities July-September 2026
SC Medicaid - SCDHHS·Effective Jul 1, 2026
South Carolina DHHS is offering free Medicaid provider training workshops from July-September 2026, with a notable shift: in-person trainings have transitioned back from virtual to in-person format at BlueCross BlueShield South Carolina's Columbia location. Billing teams should register staff for relevant workshops (Medicaid Basics, Comprehensive Web Tool, Claim-level Adjustments/TPL, ORP Enrollment, and Managed Care Enrollment) to ensure compliance with current SC Healthy Connections Medicaid processes and systems.
Low impact
Refer AmeriHealth members for care coordination and support
AmeriHealth New Jersey·Identified Jul 1, 2026
AmeriHealth is promoting clinical support programs for eligible HMO and New Jersey Insurance Company members to coordinate care, provide education, and connect members with resources between visits. This is an informational policy about available support services rather than a change to billing, coding, or coverage requirements.
Medium impact
Intravenous tocilizumab products (Revised)
Humana·Effective Jun 24, 2026
Humana Medicare Advantage updated its intravenous tocilizumab prior authorization policy (effective January 1, 2019; revised June 24, 2026). The policy covers four tocilizumab products (Actemra, Tyenne, Tofidence, Avtozma) for five FDA-approved indications: moderately to severely active rheumatoid arthritis (with prior DMARD therapy requirement), systemic juvenile idiopathic arthritis, polyarticular juvenile idiopathic arthritis, cytokine release syndrome, and giant cell arteritis. Key exclusion: combination therapy with other biologics is not covered. Prior authorization is required for all covered indications.
Medium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·Effective Jun 24, 2026
This is a revised Gamifant® (emapalumab-lzsg) prior authorization policy effective June 24, 2026, covering Medicare and Medicaid (Kentucky and South Carolina). The policy outlines coverage criteria for two indications: Primary HLH with refractory/recurrent/progressive disease or intolerance to conventional therapy, and HLH/MAS in Still's disease with inadequate response to glucocorticoids. Prior authorization is required for all requests, with initial and renewal approvals valid for 6 months.

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Archive by year

2023 2024 2025 2026

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

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

[Virginia] Clinical Criteria updates (July 2026 Newsletter)

[Virginia] Specialty pharmacy updates (July 2026 Newsletter)

[Virginia] Medication safety alerts: reducing opioid and anticholinergic risk

[Virginia] Provider data attestation

[Virginia] Reminder: provider data attestation

[Georgia] Clinical Criteria updates

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

[Georgia] Specialty pharmacy updates (July 2026 Newsletter)

[Georgia] Medication safety alerts: reducing opioid and anticholinergic risk

[Georgia] Reminder: provider data attestation

Certified Lactation Consultants Eligible to Provide Breastfeeding Instruction Sessions

Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600540 - 07/2026)

Durable Medical Equipment (DME) Program Wheelchair Diagnosis Documentation Requirements for Nursing Home Participants

Upcoming Changes to the MO HealthNet Fee Schedule

Updated Hospice Services Billing Guide

Quarterly Billing Guide Updates, Effective 7/1/2026

COVID-19 testing—Molecular and antigen updates eff. 10/1/2026

Prior Authorization Required for Select Codes Starting October 1, 2026

Prior Authorization Required for Newly Released Codes Starting July 1, 2026

Healthy Connections Medicaid Provider Training Opportunities July-September 2026

Refer AmeriHealth members for care coordination and support

Intravenous tocilizumab products (Revised)

Gamifant® (emapalumab-lzsg) (Revised)