All Insurance Policy Changes (Page 13)

Continuing from page 12. 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
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. Billing teams can upload supporting documentation (up to 10 attachments or 64 MB) to respond to payer requests through the Authorization/Referral Dashboard, streamlining the prior authorization follow-up process.
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 instead of through phone calls or faxes. This streamlines prior authorization follow-ups by allowing secure online submission of supporting clinical documentation with up to 10 attachments (64 MB total) 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 allows providers to view and respond to Requests for Additional Information (RFAI) directly within the platform instead of via phone or fax. The Authorization/Referral Dashboard now displays pending RFAI requests with payer messages, and providers can upload up to 10 attachments (64 MB total) to respond online. This streamlines the prior authorization follow-up process and eliminates manual communication channels.
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 online through the Authorization/Referral Dashboard, eliminating the need for phone calls or faxes. Billing teams can upload supporting documentation (up to 10 attachments or 64 MB) and track authorization follow-ups in a single 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 managing authorization follow-ups through calls or faxes. The billing team can upload supporting clinical documentation (up to 10 attachments or 64 MB) and track all activity from a single 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 allows providers to view and respond to Requests for Additional Information (RFAI) directly online through the Authorization/Referral Dashboard, eliminating the need for phone calls or faxes. This streamlines authorization follow-ups by enabling secure document uploads and centralized tracking of payer requests.
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 online platform instead of relying on phone calls or faxes. The billing team can upload supporting clinical documentation (up to 10 attachments, 64 MB total) through the Authorization/Referral Dashboard to expedite authorization follow-ups.
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 online portal instead of requiring phone calls or faxes. Providers can upload supporting clinical documentation (up to 10 attachments, 64 MB total) and track all authorization follow-ups from a single dashboard, streamlining the prior authorization management process.
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 managing them through phone calls, faxes, or external portals. The billing team can upload supporting clinical documentation (up to 10 attachments, 64 MB total) and track authorization follow-ups from a single 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 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 relying on calls, faxes, or external portals. This streamlines prior authorization follow-ups by enabling secure document uploads and real-time tracking through a single 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 through phone calls or faxes. The billing team can upload clinical documentation, track authorization status in a single dashboard, and monitor response deadlines online.
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 or faxes. The billing team can track authorization follow-ups in a single dashboard and upload supporting documentation (up to 10 attachments or 64 MB) to respond to payer requests online.
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) online through the Authorization/Referral Dashboard, eliminating the need for phone calls or faxes. Billing teams can upload supporting documentation directly within the platform (up to 10 attachments or 64 MB total) and track all authorization follow-ups from a single dashboard.
High impact
Upcoming Changes to Medicaid Eligibility for Noncitizens
Nebraska Medicaid·Effective Oct 1, 2026
Effective October 1, 2026, Nebraska Medicaid eligibility for noncitizens will be significantly restricted. Noncitizens without green card status in categories such as refugees, asylees, parolees, VAWA applicants, trafficking victims, and others will lose Medicaid coverage, even if currently enrolled. Billing teams must identify affected patients before the cutoff and prepare for coverage terminations and claim denials for ineligible members on or after October 1, 2026.
Medium impact
Point32Health Payment Policy updates
Harvard Pilgrim Health Care·Effective Sep 1, 2026
Point32Health is implementing minor administrative updates to 18 payment policies effective 9/1/2026 and 11/1/2026, with the most significant change being a clarification that 'once-yearly reimbursement' means reimbursement every 365 days in the Laboratory and Pathology policy. Additionally, two CPT codes (99459 and 76376/76377) will be newly denied for Tufts Health Direct members effective 11/1/2026.
Medium impact
Triptans (Revised)
Humana·Identified Sep 4, 2026
This is a step therapy policy for triptan medications (used to treat acute migraine attacks) under Humana Medicare Advantage plans. The policy requires members to have tried TWO generic triptan products (sumatriptan, rizatriptan, or naratriptan) before coverage is approved for other triptan formulations. The policy was last revised on September 3, 2026, and includes comprehensive contraindications and warnings related to cardiovascular and neurological risks.
Medium impact
Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) prior authorization policy for Medicaid in Florida, Kentucky, and South Carolina, effective January 1, 2023, with a revision date of September 4, 2026. The policy requires prior authorization for this subcutaneous HER2-positive breast cancer treatment and includes step therapy requirements (with an exception for Florida Medicaid). Key approval criteria include HER2-positive breast cancer diagnosis, specified treatment combinations or monotherapy regimens, and prior treatment/intolerance to Kanjinti or Trazimera, with exclusions for concurrent Kadcyla use and gastric/GEJ/esophageal carcinoma.
High impact
Gene Expression Profiling for Cancer Indications - Medicare Advantage (Revised)
Humana·Effective May 1, 2026
This is a revised Medicare Advantage policy (HUM-1092-015) governing coverage for Gene Expression Profiling tests used in cancer diagnosis and risk stratification. The policy became effective 05/01/2026 and consolidates coverage rules across multiple cancer types (breast, prostate, lung, bladder, melanoma, colon) with jurisdiction-specific LCD requirements based on MAC contractors. The policy references multiple MolDX and molecular testing LCDs that billing teams must follow by geographic region.
High impact
Upper and Lower Extremity Magnetic Resonance Imaging (MRI) - Medicare Advantage (Revised)
Humana·Effective Jul 1, 2026
Humana Medicare Advantage has updated its medical necessity criteria for upper and lower extremity MRI (CPT 73221, 73222, 73223, 73721, 73722, 73723). The policy, effective July 1, 2026, establishes specific clinical indications required for MRI approval, including mandatory completion of first-line imaging (ultrasound or x-ray) before MRI for most conditions. This replaces previous guidance and applies across all Medicare Advantage jurisdictions.
Medium impact
Herceptin Hylecta (trastuzumab and hyaluronidase oysk) (New)
Humana·Effective Sep 4, 2026
Humana has implemented a new prior authorization policy for Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) effective September 4, 2026, for Medicare Advantage beneficiaries with HER2-positive breast cancer. The policy requires step therapy with preferred trastuzumab biosimilars (Trazimera or Ogivri for Part B; Trazimera or Kanjinti for Part D) before approval, unless patients have documented intolerance or contraindication. Prior authorization is required for all new requests and renewals.
Medium impact
08-28-2026 Coming soon: New provider enrollment and credentialing portal IM IE LA OC SAC SD
Molina Healthcare·Effective Oct 26, 2026
Molina Healthcare is launching a new Provider Network Management Portal on October 26, 2026, that will replace email and paper-based provider enrollment and credentialing submissions for directly contracted providers. All direct provider enrollment and credentialing requests must be submitted through this new portal starting that date. This change does not affect delegated IPAs (which use D360) or Availity functionality (claims, prior auth, member panels).
Low impact
CME Webinar: Oral Health In Your Pediatric Office
UPMC Health Plan·Identified Sep 4, 2026
This is a CME education webinar announcement for pediatric providers covering oral health integration and fluoride varnish application techniques. No billing codes, coverage changes, or reimbursement adjustments are involved—this is purely an educational offering with individual provider registration required.
High impact
Attention Nevada Medicaid-enrolled 340B Covered Entities: Reminder: Nevada Medicaid Fee-For-Service (FFS) Will Integrate the 340B Ceiling Price into the 340B Reimbursement Methodology Beginning October 1, 2026
Nevada Medicaid·Effective Oct 1, 2026
Starting October 1, 2026, Nevada Medicaid Fee-For-Service will incorporate the 340B ceiling price into its outpatient drug reimbursement methodology. When the 340B ceiling price is the lowest applicable value in the established drug reimbursement logic, it will be used for reimbursement calculations. Covered entities must ensure their 340B Acquisition and Accountability Cost (AAC) is submitted to Nevada Medicaid, and pricing disputes must follow HRSA's 340B Administrative Dispute Resolution process.
High impact
[Ohio] Submission Requirements for Uniform Itemized Bills
CareSource·Effective Sep 3, 2026
CareSource (Ohio Medicaid, Marketplace, and MyCare Ohio) has established new submission requirements for itemized bills effective immediately. All itemized bills must be submitted in text-only format with specific structural requirements including MM/DD/YYYY date format, required header fields (Date, Revenue Code, CPT Code, Description, Quantity, Charges), and reconcilable charges at claim and revenue code levels. Noncompliance may result in processing delays, requests for corrected documentation, or claim denial.

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2023 2024 2025 2026

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

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

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

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

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

Upcoming Changes to Medicaid Eligibility for Noncitizens

Point32Health Payment Policy updates

Triptans (Revised)

Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Revised)

Gene Expression Profiling for Cancer Indications - Medicare Advantage (Revised)

Upper and Lower Extremity Magnetic Resonance Imaging (MRI) - Medicare Advantage (Revised)

Herceptin Hylecta (trastuzumab and hyaluronidase oysk) (New)

08-28-2026 Coming soon: New provider enrollment and credentialing portal IM IE LA OC SAC SD

CME Webinar: Oral Health In Your Pediatric Office

Attention Nevada Medicaid-enrolled 340B Covered Entities: Reminder: Nevada Medicaid Fee-For-Service (FFS) Will Integrate the 340B Ceiling Price into the 340B Reimbursement Methodology Beginning October 1, 2026

[Ohio] Submission Requirements for Uniform Itemized Bills