All Insurance Policy Changes (Page 1310)

Continuing from page 1309. 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
[Ohio] Medical Policies and Clinical UM Guidelines
Anthem BCBS·Effective Aug 1, 2026
Anthem Blue Cross and Blue Shield updated medical policies and clinical utilization management guidelines effective August 1, 2026, for Ohio, Indiana, Kentucky, Missouri, and Wisconsin. Changes include a new gene therapy policy for Wiskott-Aldrich Syndrome (requiring prior authorization) and revisions to bariatric surgery coverage guidelines, adding three new endoscopic procedures to the medically necessary list and moving vertical banded gastroplasty to non-medically necessary.
Medium impact
[Ohio] Genetic testing claims for FEP members: medical records required for review
Anthem BCBS·Identified May 29, 2026
Anthem Ohio now requires medical records to be submitted for review with all genetic testing claims for Federal Employee Program (FEP) members. This adds a documentation requirement that could delay claim processing if records are not included.
High impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (June 2026 Newsletter)
Anthem BCBS·Effective Jul 1, 2026
Carelon Medical Benefits Management has updated prior authorization requirements across multiple clinical areas (Genetic Testing, Cardiovascular, Radiology, Sleep, Musculoskeletal, and Radiation Oncology) effective on staggered dates from July 1, 2026 through October 1, 2026. These changes apply differently to Medicaid, Medicare Advantage, and Commercial plans in Ohio, requiring the billing team to implement plan-specific prior authorization workflows for affected service lines.
Medium impact
[Virginia] Manage physical health P2P conversations online — mid‑June
Anthem BCBS·Effective Jun 16, 2026
Virginia Medicaid (HealthKeepers/Anthem) is launching an online Peer-to-Peer (P2P) scheduling enhancement within Availity Essentials that allows providers to schedule and cancel P2P conversations electronically for physical health and behavioral health services. This replaces the current phone/email submission process and provides 24/7 self-service scheduling with real-time visibility into appointments.
High impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (June 2026 Newsletter)
Anthem BCBS·Effective Jul 1, 2026
Carelon Medical Benefits Management has issued multiple precertification/prior authorization requirement updates across multiple service lines (Radiology, Cardiovascular, Sleep, Genetic Testing, Radiation Oncology, and Musculoskeletal) effective on staggered dates from July 1, 2026 through October 1, 2026. These changes apply across Commercial, Medicare Advantage, and Medicaid plans in Virginia, requiring billing teams to update prior authorization submission workflows for each affected service line by their respective effective dates.
Low impact
Virtual Assistant Now Available on the Medicaid Tort Portal
Texas Medicaid·Identified May 29, 2026
TMHP has launched a new virtual assistant named Tim available 24/7 on the Medicaid Tort Portal to help providers with third party liability reporting, correspondence status, lien amounts, and payment confirmation. This is a system enhancement that provides additional support resources for tort-related billing processes.
Low impact
Post-Visit Surveys Support Medicare Advantage Member Experiences
BCBS Texas·Effective May 28, 2026
Blue Cross Blue Shield of Texas has launched a new post-visit survey program for Medicare Advantage members using Press Ganey to collect patient experience data after primary care visits. Members will receive surveys via email or mail after routine or sick visits (maximum once every 6 months) to support CMS Star Ratings and quality improvement efforts.
Medium impact
Use Machinify’s TrueCost Portal to Submit Medical Records for Commercial Member Claims
BCBS Texas·Effective Sep 1, 2026
Starting September 1, 2026, providers must submit medical records for commercial member claims through Machinify's TrueCost portal instead of faxing or mailing to BCBSTX. Government program claims will continue to be submitted directly to BCBSTX as before.
Low impact
How a Regence behavioral health care manager helps members find their path to wellness
Regence BlueCross BlueShield of Oregon·Identified May 29, 2026
Regence is promoting its integrated behavioral health care management services, available at no cost to members across Idaho, Oregon, Utah, and Washington. Care managers (nurses, behavioral health clinicians, social workers, and pharmacists) proactively coordinate care, connect members to benefits and providers, and support treatment planning. This is an informational policy about existing care management services rather than a new billing or coverage requirement.
Low impact
Regence care manager connects Utah family to lifesaving, affordable care
Regence BlueCross BlueShield of Oregon·Identified May 29, 2026
This is a provider news article highlighting Regence's care management services and a success story about a care manager assisting a family with rare metabolic disorder formula coverage. It is NOT a policy change affecting billing, codes, or reimbursement—it is marketing/informational content about existing care management services available at no cost to members in Idaho, Oregon, Utah, and Washington.
High impact
Legacy Health negotiations
Regence BlueCross BlueShield of Oregon·Effective May 6, 2026
Legacy Health has returned to in-network status for Regence health plan members in Oregon and Southwest Washington effective immediately (as of May 6, 2026). All claims from Legacy Health providers during the out-of-network period will be reprocessed as in-network. Billing teams must update provider directories and ensure claims are submitted with in-network status going forward.
Low impact
Supporting your child’s mental health: Guidance from our behavioral health care team
Regence BlueCross BlueShield of Oregon·Effective May 12, 2026
This is a patient education and care guidance policy from Regence outlining behavioral health support resources for pediatric mental health. It highlights available virtual mental health care networks (Bend Health, Charlie Health, Equip, NOCD, Headway, Rula, Grow Therapy, Talkspace, Meru Health) and encourages parents to access free Care Management services through customer service. This is informational guidance rather than a billing or coverage change.
Medium impact
[California] Required 2026 Model of Care Training Now Available
Anthem BCBS·Identified May 28, 2026
Anthem Blue Cross is requiring all contracted care providers for Medicare Advantage Special Needs Plans (SNPs) to complete annual 2026 Model of Care training. This is a CMS-mandated educational requirement covering SNP details, cost sharing, data sharing, Interdisciplinary Care Team participation, and member health risk assessments. The training is now available and must be completed to maintain compliance with Medicare Advantage SNP participation requirements.
High impact
[California] Enhancing claims accuracy: new process for inpatient sepsis and some newborn DRG submissions with full medical records
Anthem BCBS·Effective Jul 1, 2026
Effective July 1, 2026, Anthem Blue Cross (Medi-Cal Managed Care in California) will require complete medical records to be submitted with inpatient sepsis and certain newborn DRG claims at the time of initial submission to validate correct DRG assignment. Claims submitted without medical records may not be eligible for reimbursement until records are provided. Normal newborn MS DRG 795 and APR DRG 640-1 are excluded from this requirement.
Medium impact
[California] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (June 2026 Newsletter)
Anthem BCBS·Effective Sep 1, 2026
Carelon Medical Benefits Management has updated prior authorization requirements for Medicare Advantage plans effective September 1, 2026, across six clinical areas: Sleep, Cardiovascular, Radiation Oncology, Radiology, and Genetic Testing. The billing team must identify which services in these specialties now require precertification and update workflow processes accordingly.
Low impact
[New York] Manage physical health P2P conversations online — mid‑June
Anthem BCBS·Effective Jul 15, 2026
Anthem Blue Cross Blue Shield New York is launching an online Peer-to-Peer (P2P) scheduling enhancement on the Availity Essentials platform, allowing providers to schedule and cancel P2P conversations electronically for physical health and behavioral health services instead of using phone or email. Pharmacy P2P requests will continue through existing processes.
Medium impact
[New York] Required 2026 Model of Care Training Now Available
Anthem BCBS·Identified May 28, 2026
Anthem Medicare Advantage Special Needs Plans (SNPs) in New York require all contracted providers to complete annual 2026 Model of Care training. This CMS-mandated education covers plan specifics, cost sharing, data sharing, Interdisciplinary Care Team participation, and member health risk assessments. Training is now available and completion is required for continued network participation.
Low impact
[Ohio] Manage physical health P2P conversations online — mid‑June
Anthem BCBS·Effective Jul 15, 2026
Anthem Blue Cross and Blue Shield Ohio Medicaid (MyCare Ohio) is launching an online portal enhancement in mid-July 2026 that allows providers to schedule and cancel Peer-to-Peer (P2P) conversations electronically through Availity Essentials, replacing the current phone/email submission process. This applies to physical health and behavioral health services; pharmacy P2P requests continue using existing processes.
Medium impact
[Ohio] Required 2026 Model of Care Training Now Available
Anthem BCBS·Identified May 28, 2026
Anthem is reminding contracted care providers for Medicare Advantage Special Needs Plans (SNPs) in Ohio that the annual 2026 Model of Care training is now available and required per CMS regulations. This training covers SNP program details, cost sharing, data sharing, Interdisciplinary Care Team participation, health risk assessments, and care coordination. Providers must complete this training to maintain compliance and ensure quality care delivery for SNP members.
High impact
[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
Anthem BCBS·Effective Sep 19, 2026
Carelon Medical Benefits Management has updated clinical appropriateness guidelines for Virginia Medicaid effective September 19, 2026, affecting imaging authorization requirements across radiology, cardiology, and sleep medicine. Changes include expanded indications for brain CT, vascular imaging, and cardiac procedures; removal of certain non-culprit vessel interventions post-STEMI; updated sleep apnea testing criteria; and alignment with 2024-2025 professional society guidelines. Billing teams must update prior authorization workflows and documentation requirements for affected imaging and procedural codes.
Low impact
[Virginia] How to locate the UM denial letter in Availity Essentials
Anthem BCBS·Effective May 27, 2026
This is an instructional bulletin from Anthem Virginia Medicaid explaining how to locate UM (Utilization Management) denial letters within the Availity Essentials portal. The policy clarifies that denial letters are filed under authorization cases, not in the Claims section, and provides step-by-step navigation instructions for providers to access these documents.
Medium impact
[Virginia] Required 2026 Model of Care Training Now Available
Anthem BCBS·Identified May 28, 2026
Anthem Medicare Advantage Special Needs Plan (SNP) contracted providers in Virginia are required to complete annual 2026 Model of Care training. This training covers SNP details, cost sharing, data sharing, Interdisciplinary Care Team participation, and member health risk assessments. Training is now available online and completion is a CMS-mandated requirement for all contracted care providers.
Medium impact
[Georgia] Manage physical health Peer‑to‑Peer conversations online — mid‑May
Anthem BCBS·Effective May 15, 2026
Anthem Blue Cross and Blue Shield (Georgia) is launching an online peer-to-peer (P2P) conversation scheduling and cancellation tool within the Availity Essentials Provider Platform, eliminating the need for phone or email submission. This enhancement applies only to physical health services initially, with behavioral health and pharmacy services following existing processes. The feature will be available mid-May 2026.
High impact
[Georgia] August 1 specialty pharmacy criteria updates — PA changes may limit coverage
Anthem BCBS·Effective Aug 1, 2026
Effective August 1, 2026, Georgia's Anthem Blue Cross Blue Shield is implementing new clinical criteria for 21 specialty pharmacy drugs managed by their medical specialty drug review team. These updated prior authorization requirements may result in coverage denials for previously covered services, particularly for non-oncology specialty medications. Billing teams must verify medical necessity against the new clinical criteria before claim submission.
Medium impact
[Georgia] Genetic testing claims for FEP members: medical records required for review
Anthem BCBS·Identified May 28, 2026
Anthem FEP (Federal Employee Program) now requires medical records to be submitted for review with all genetic testing claims in Georgia. This adds a documentation requirement that could delay claim processing if records are not provided upfront.

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Archive by year

2023 2024 2025 2026

[Ohio] Medical Policies and Clinical UM Guidelines

[Ohio] Genetic testing claims for FEP members: medical records required for review

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (June 2026 Newsletter)

[Virginia] Manage physical health P2P conversations online — mid‑June

[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (June 2026 Newsletter)

Virtual Assistant Now Available on the Medicaid Tort Portal

Post-Visit Surveys Support Medicare Advantage Member Experiences

Use Machinify’s TrueCost Portal to Submit Medical Records for Commercial Member Claims

How a Regence behavioral health care manager helps members find their path to wellness

Regence care manager connects Utah family to lifesaving, affordable care

Legacy Health negotiations

Supporting your child’s mental health: Guidance from our behavioral health care team

[California] Required 2026 Model of Care Training Now Available

[California] Enhancing claims accuracy: new process for inpatient sepsis and some newborn DRG submissions with full medical records

[California] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (June 2026 Newsletter)

[New York] Manage physical health P2P conversations online — mid‑June

[New York] Required 2026 Model of Care Training Now Available

[Ohio] Manage physical health P2P conversations online — mid‑June

[Ohio] Required 2026 Model of Care Training Now Available

[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines

[Virginia] How to locate the UM denial letter in Availity Essentials

[Virginia] Required 2026 Model of Care Training Now Available

[Georgia] Manage physical health Peer‑to‑Peer conversations online — mid‑May

[Georgia] August 1 specialty pharmacy criteria updates — PA changes may limit coverage

[Georgia] Genetic testing claims for FEP members: medical records required for review