All Insurance Policy Changes (Page 1316)

Continuing from page 1315. 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
Deadline to transition to Community First Services and Supports extended
Minnesota Medicaid (MHCP)·Identified May 22, 2026
Minnesota Department of Human Services extended the deadline for Personal Care Assistance (PCA) and Consumer Support Grant (CSG) members to transition to Community First Services and Supports (CFSS) from the original deadline to September 30, 2027. Billing teams must verify member transition status and ensure proper service coding during the extended transition period. Extended PCA services will no longer be authorized after September 30, 2026.
High impact
Whole Exome Sequencing (WES) Clinical Criteria (CPT 81415, 81416, 81417)
Arkansas Medicaid·Effective May 22, 2026
Arkansas has issued new clinical criteria for Whole Exome Sequencing (WES) billing under CPT codes 81415, 81416, and 81417. This is a fresh policy update (1 day old) that establishes procedural coding requirements and likely clinical necessity thresholds for WES testing. The billing team must obtain and review the full policy document to understand specific clinical criteria, prior authorization requirements, and documentation needs.
High impact
Potential scam related to revalidation
Minnesota Medicaid (MHCP)·Identified May 22, 2026
The Minnesota Department of Human Services has issued a fraud alert regarding unauthorized phone calls impersonating DHS staff requesting enrollment and private health information under the guise of revalidation. Billing and administrative staff must immediately educate themselves and providers on this scam, verify caller identity through official channels (651-431-2700), and never provide sensitive information over unsolicited calls. Legitimate revalidation requests will be in writing and will not solicit patient/recipient data over the phone.
Medium impact
Physical therapy (PT) and occupational therapy (OT) visits now displaying in MN–ITS, claims reprocessed
Minnesota Medicaid (MHCP)·Effective Jan 1, 2026
Minnesota Health Care Programs has updated the MN–ITS eligibility system to accurately display PT and OT visit utilization since January 1, 2026, and has reprocessed all PT/OT claims with dates of service from that date forward. Reprocessed claims will appear on the May 19, 2026 remittance advice. A broad CPT code pull during reprocessing may have affected other services (such as Early Intensive Developmental and Behavioral Intervention), but there is no payment impact on non-PT/OT services.
Medium impact
Whole Genome Sequencing (WGS) Clinical Criteria (CPT 81425, 81426, 814271)
Arkansas Medicaid·Effective May 22, 2026
Arkansas has updated clinical criteria for Whole Genome Sequencing (WGS) billing codes CPT 81425, 81426, and 81427. This is a brand new policy effective immediately that establishes specific medical necessity requirements for these genetic testing procedures. Billing teams must review the detailed clinical criteria document to understand what documentation and patient scenarios qualify for coverage before submitting claims.
Low impact
[New York] Utilization management: prioritizing appropriate care and transparency
Anthem BCBS·Effective May 20, 2026
Anthem Blue Cross has published updated utilization management (UM) guidance for New York Medicaid clarifying the prior authorization submission process, support resources, and UM decision-making standards. The policy reinforces existing submission methods (Availity, fax, phone) and 24/7 preapproval availability, with no substantive changes to billing workflows or authorization requirements.
Low impact
[New York] Navigating health with confidence through the Complex Case Management Program
Anthem BCBS·Identified May 21, 2026
Anthem Blue Cross has published an informational bulletin about their Complex Case Management program for New York Medicaid members. This is an educational resource describing existing case management services and referral processes—no billing codes, coverage rules, or reimbursement changes are introduced.
Low impact
[New York] Learn about members’ rights and responsibilities
Anthem BCBS·Identified May 21, 2026
This is an informational bulletin directing Anthem Blue Cross New York providers to review the Members' Rights and Responsibilities section in the provider manual. No billing process, coding, or coverage changes are implemented—this is a reminder to ensure awareness of member rights and responsibilities as part of quality management requirements.
Low impact
[Virginia] Member support resource — Complex Case Management program
Anthem BCBS·Identified May 21, 2026
This is an informational bulletin about Anthem HealthKeepers Plus's existing Complex Case Management program for Virginia Medicaid members. It outlines how members and providers can refer patients to the program for comprehensive support with illness management, care coordination, and transition assistance. No billing, coverage, or operational changes are announced.
Low impact
[Virginia] Efficacy through efficiency — emphasizing utilization management
Anthem BCBS·Effective May 20, 2026
Anthem HealthKeepers Plus (Virginia Medicaid) has published clarification on their utilization management (UM) process, emphasizing that UM decisions are based on appropriateness of care and member coverage. The policy explicitly prohibits financial incentives or performance metrics that reward denials, and reaffirms access to physician reviewers for UM appeal discussions. This is informational guidance rather than a substantive policy change.
Low impact
[Virginia] Shared empowerment — knowing member rights and responsibilities
Anthem BCBS·Identified May 21, 2026
This is an informational bulletin reminding Virginia Medicaid providers to review and communicate member rights and responsibilities as outlined in the Provider Manual. No billing workflow, coding, or coverage changes are implemented—this is a quality management awareness notice directing providers to consult existing documentation.
Medium impact
[Virginia] Prior authorization and step therapy updates for medications billed under the medical benefit
Anthem BCBS·Effective Jul 1, 2026
Effective July 1, 2026, four specialty pharmacy drugs billed under the medical benefit for Virginia Medicaid now require prior authorization: Fesilty (fibrinogen, human-chmt), Loargys (pegzilarginase-nbln), Vykoura (leucovorin calcium), and Yuviwel (navepegritide). Billing teams must obtain prior authorization before claims are submitted for these medications, and National Drug Codes (NDCs) must be included on all medical claims for processing.
Low impact
Register for Long-Term Care Webinar on June 17
Texas Medicaid·Effective Jun 17, 2026
TMHP is offering a free educational webinar on antibiotic stewardship in long-term care facilities, scheduled for June 17 from noon to 1 p.m. Central time. This is an informational announcement about continuing education opportunities for nursing staff and administrators, not a policy change affecting billing operations.
Medium impact
2026-05-21 - Critical Access Hospitals: Download Your FY 2025 PEPPER
Medicare/CMS·Identified May 21, 2026
CMS released FY 2025 PEPPER reports for critical access hospitals to help review billing patterns and identify potential coding issues. A new HCPCS code G0136 was finalized for physical activity and nutrition risk assessments as an add-on to E/M visits or annual wellness visits every 6 months.
Medium impact
8,000 Participate in 2026 CDPHP Workforce Team Challenge
CDPHP·Identified May 21, 2026
Failed to analyze policy change
High impact
Updated: Corrected Claims Must Be Filed Within 15 Months of Original Claim Finalization Date
Highmark·Effective Sep 1, 2026
Highmark has updated their policy requiring all corrected claims to be filed within 15 months (455 calendar days) of the original claim's finalization date, effective September 1, 2026. Corrected claims submitted after this timeframe will be denied for failing to meet timely filing requirements.
Medium impact
[Virginia] VA precertification/prior authorization list change notification
Anthem BCBS·Effective Jun 1, 2026
Effective June 1, 2026, Anthem Blue Cross and Blue Shield in Virginia is adding two durable medical equipment (DME) services to its prior authorization requirements: compression devices for lymphedema and pneumatic compression devices for deep vein thrombosis prevention in the home setting (HCPCS code E0650). Providers must obtain prior authorization before delivering these services or claims will be deemed ineligible for payment.
Medium impact
[New York] Precertification/prior authorization list change notification
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem Blue Cross and Blue Shield is adding four new services to its precertification/prior authorization requirements for New York commercial plans: PFAS testing (0589U), electrical stimulation devices for pain (E0765), allogeneic bone marrow-derived mesenchymal stromal cell therapy (J3402), and encapsulated cell therapy for degenerative ocular disease (J3403). Billing teams must implement prior auth requirements for these codes before the effective date to avoid claim denials.
Medium impact
[New York] Carelon Medical Benefits Management, Inc. code updates
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, three surgical procedure codes (Q4369, 30970T, 0971T) will require prior authorization through Carelon Medical Benefits Management for Medicare Advantage plans in New York. Providers must submit authorization requests via the Carelon provider portal, Availity Essentials, or email before performing these procedures.
Medium impact
[Ohio] MCG Care Guidelines 30th edition
Anthem BCBS·Effective Jun 1, 2026
Anthem Blue Cross Blue Shield is upgrading to MCG Care Guidelines 30th edition effective June 1, 2026, introducing new prior authorization guidelines for behavioral health (psychosocial education, ketamine for treatment-resistant depression), cardiac procedures (transcatheter mitral valve repair), rehabilitation facility care for cardiac disorders, and pediatric bipolar disorder assessments. Billing and clinical teams must update prior authorization workflows and documentation requirements to align with these new guidelines.
Medium impact
[Virginia] MCG Care Guidelines 30th edition
Anthem BCBS·Effective Jun 1, 2026
HealthKeepers, Inc. (Virginia Medicaid) is upgrading to MCG Care Guidelines 30th edition effective June 1, 2026. This introduces new clinical guidelines for psychosocial education, ketamine for treatment-resistant depression, transcatheter mitral valve repair, cardiac rehabilitation, pediatric bipolar disorder assessments, and dual organ transplant indications. Billing and prior authorization workflows may require updates to align with these new guideline modules.
High impact
[Virginia] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·Effective May 14, 2026
Anthem Virginia has updated multiple medical policies and clinical utilization management guidelines effective May 14, 2026, affecting prior authorization requirements, coverage criteria, and medical necessity determinations across various service categories including gene therapy, durable medical equipment, surgical procedures, and diagnostic testing. Some services previously covered may now be found not medically necessary under revised criteria. All affected policies must be reviewed and implemented in billing workflows before the effective date.
Medium impact
[Georgia] Prior authorization requirement changes
Anthem BCBS·Effective Jun 1, 2026
Effective June 1, 2026, Anthem Blue Cross Blue Shield Georgia is adding compression devices for lymphedema and pneumatic compression devices for DVT prevention (HCPCS code E0658) to its prior authorization requirements. Billing teams must obtain prior authorization before billing this DME code for Georgia commercial members, or claims will be denied.
Medium impact
[Georgia] Clarification to reimbursement policy update: Observation Services — Facility
Anthem BCBS·Effective Jun 1, 2026
Effective June 1, 2026, Anthem Georgia's observation services reimbursement policy now requires designated observation status to be at least 8 hours and not exceed 24 hours. Billing teams must validate observation service length of stay against these thresholds and deny or adjust claims that fall outside this window. Balance billing members for this policy change is prohibited.
Medium impact
Reimbursement Rate Updates for Certain CSHCN Procedure Codes Effective June 1, 2026
Texas Medicaid·Effective Jun 1, 2026
The Children with Special Health Care Needs (CSHCN) Services Program is updating reimbursement rates for multiple procedure codes effective June 1, 2026. The changes affect various service categories including dialysis, surgical procedures, physician-administered drugs, medical supplies, and telehealth services.

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Archive by year

2023 2024 2025 2026

Deadline to transition to Community First Services and Supports extended

Whole Exome Sequencing (WES) Clinical Criteria (CPT 81415, 81416, 81417)

Potential scam related to revalidation

Physical therapy (PT) and occupational therapy (OT) visits now displaying in MN–ITS, claims reprocessed

Whole Genome Sequencing (WGS) Clinical Criteria (CPT 81425, 81426, 814271)

[New York] Utilization management: prioritizing appropriate care and transparency

[New York] Navigating health with confidence through the Complex Case Management Program

[New York] Learn about members’ rights and responsibilities

[Virginia] Member support resource — Complex Case Management program

[Virginia] Efficacy through efficiency — emphasizing utilization management

[Virginia] Shared empowerment — knowing member rights and responsibilities

[Virginia] Prior authorization and step therapy updates for medications billed under the medical benefit

Register for Long-Term Care Webinar on June 17

2026-05-21 - Critical Access Hospitals: Download Your FY 2025 PEPPER

8,000 Participate in 2026 CDPHP Workforce Team Challenge

Updated: Corrected Claims Must Be Filed Within 15 Months of Original Claim Finalization Date

[Virginia] VA precertification/prior authorization list change notification

[New York] Precertification/prior authorization list change notification

[New York] Carelon Medical Benefits Management, Inc. code updates

[Ohio] MCG Care Guidelines 30th edition

[Virginia] MCG Care Guidelines 30th edition

[Virginia] Medical Policies and Clinical Utilization Management Guidelines update

[Georgia] Prior authorization requirement changes

[Georgia] Clarification to reimbursement policy update: Observation Services — Facility

Reimbursement Rate Updates for Certain CSHCN Procedure Codes Effective June 1, 2026