All Insurance Policy Changes (Page 1317)

Continuing from page 1316. 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
Reimbursement Rate Updates for Radiation Oncology Procedure Codes Effective January 1, 2026
Texas Medicaid·Effective Jan 1, 2026
Texas Medicaid and CSHCN Services Program is implementing reimbursement rate updates for radiation oncology procedure codes effective January 1, 2026. TMHP will automatically identify and reprocess affected claims, with adjustments appearing in future Remittance and Status Reports.
Medium impact
Texas Health and Human Services Commission Notifies Providers of the SFY 2025-29 Financial Compliance Report Information
Texas Medicaid·Identified May 20, 2026
Texas Health and Human Services Commission has established new Financial Compliance Reporting requirements for Long-term Services and Supports (LTSS) and home health providers for state fiscal years 2025-2029. Providers must submit attendant and direct care staff compensation data to meet federal requirements under CMS's Ensuring Access to Medicaid Services Final Rule.
Medium impact
Provide Records To Support Risk Adjustment Data Validation Audits for Medicare Advantage
BCBS Texas·Effective Mar 1, 2026
Blue Cross and Blue Shield of Texas will be requesting medical records from Medicare Advantage providers to support CMS Risk Adjustment Data Validation (RADV) audits beginning March 2026. Providers must respond promptly to medical record requests from Advantmed (BCBSTX's vendor) for sampled patients from payment years 2020, 2021, 2023, and 2024.
Medium impact
Single pharmacy benefit manager update
Minnesota Medicaid (MHCP)·Effective Jan 1, 2028
Minnesota Department of Human Services has contracted with Prime Therapeutics as the single pharmacy benefit manager (sPBM) to administer outpatient pharmacy benefits for Minnesota Health Care Programs members in managed care plans, effective January 1, 2028. Billing teams must prepare for a transition in how pharmacy claims are processed and routed for these plans, separate from the existing fee-for-service program.
High impact
System issue affecting certain Early Intensive Developmental and Behavioral Intervention (EIDBI) claims resolved
Minnesota Medicaid (MHCP)·Effective Jan 1, 2025
Minnesota Health Care Programs (MHCP) has resolved a system issue that incorrectly denied certain EIDBI claims with an invalid Place of Service 11 edit. Affected claims billed with specific CPT and HCPCS codes with modifier UB for dates of service from January 1, 2025 through May 6, 2026 can now be reprocessed by DHS or resubmitted by providers.
Low impact
Waiver and AC Resources and MN–ITS Training certificates for May session sent
Minnesota Medicaid (MHCP)·Effective May 20, 2026
The Minnesota Department of Human Services has distributed certificates of completion to providers who attended Waiver and Alternative Care (AC) Resources and MN–ITS Training sessions in May 2026. Certificates were sent to providers' MN–ITS mailbox under their registered National Provider Identifier (NPI) and should appear in the 'Miscellaneous Received' folder under 'PRVLTR' by end of business May 20, 2026. This is an informational notification with no billing or claims processing impact.
High impact
Early Intensive Developmental and Behavioral Intervention (EIDBI) claim denials for services billed with CPT code H0046 UB resolved
Minnesota Medicaid (MHCP)·Effective May 20, 2026
Minnesota Health Care Programs (MHCP) has resolved a system issue that incorrectly denied EIDBI claims billed with CPT code H0046 UB for dates of service from Dec. 16, 2025 through Jan. 27, 2026. Affected providers can either allow DHS to reprocess claims automatically or submit manual rebills. Billing teams should identify impacted claims and take action to recover denied revenue.
Low impact
PacificSource Welcomes Community to PACE Open House
PacificSource Health Plans·Effective Jul 1, 2026
PacificSource is launching a new PACE (Program of All-Inclusive Care for the Elderly) program in Lane County, Oregon, with an official grand opening on July 1, 2026. This is a new Medicare service offering for adults 55+ with complex medical and social needs, requiring billing teams to understand eligibility, referral processes, and potential billing implications for PACE-covered services.
High impact
Update on H0032 and H0046 reimbursement rates for EIDBI services
Minnesota Medicaid (MHCP)·Effective Apr 29, 2026
Minnesota Health Care Programs (MHCP) corrected an underpayment issue affecting EIDBI service codes H0046 UB (Travel Time) and H0032 UB (Individual Treatment Planning and Progress Monitoring) for claims billed March 25–April 28, 2026. Reimbursement rates are now correct as of April 29, 2026. Providers with impacted claims can request DHS reprocessing or submit replacement claims.
High impact
[California] 2026 California EAE DSNP Quick Reference Guide
Anthem BCBS·Effective May 1, 2025
Anthem is launching the 2026 California EAE DSNP (Exclusively Aligned Enrollment Dual Eligible Special Needs Plan) in 16 counties, integrating Medicare and Medi-Cal Managed Care under one plan. Billing teams must use network IDs CAEAEDSNP001 (Medicare primary) and CADUALCAID01 (Medi-Cal secondary), submit single claims with one member ID for both Medicare and Medicaid services, and recognize that care providers were pre-enrolled from existing Medicare PPO networks effective May 1, 2025.
Medium impact
Cancellation of System Maintenance Outage Scheduled for June 5–7, 2026
Texas Medicaid·Identified May 19, 2026
The previously scheduled TMHP system maintenance outage for June 5-7, 2026 has been cancelled. Healthcare providers will have normal system access during those dates and can continue regular billing and administrative operations without interruption.
High impact
Subject Information Letter No. 2026-11 ICD10
Texas Medicaid·Identified May 19, 2026
Texas HHSC has updated their Related Conditions List by removing invalid ICD-10 diagnosis codes and adding new corresponding ICD-10 codes. This replaces the previous 2024 guidance and affects billing for persons with related conditions in Texas Medicaid programs.
Low impact
Men’s mental health: Understanding stigma and encouraging conversations
Cigna·Identified May 19, 2026
Cigna Healthcare has published educational guidance on men's mental health to help providers understand stigma and encourage conversations. This is an informational resource highlighting existing mental health services and tools available to support male patients.
Medium impact
Assess Childhood and Adolescent Weight and Nutrition and Activity Counseling
BCBS Texas·Effective May 18, 2026
BCBSTX requires providers to document BMI percentile, nutrition counseling, and physical activity counseling for children ages 3-17 during well-child or sick visits. This is for NCQA quality measure tracking and includes specific documentation requirements for counseling content.
Medium impact
New authorization requirements for manual irrigation systems and rectal catheters effective July 1
Minnesota Medicaid (MHCP)·Effective Jul 1, 2026
Effective July 1, 2026, Minnesota Health Care Programs (MHCP) is reducing prior authorization requirements for manual transanal irrigation systems (A4459) and rectal catheters (A4453). Prior auth is now required only for quantities exceeding coverage limits: one manual system per dispensing (up to 4 per year) and up to 31 rectal catheters per month. Electronic transanal irrigation systems (A4479) continue to require authorization always with specific clinical documentation.
High impact
Avoid This Error When Submitting MSK Authorization Requests
Highmark·Effective May 1, 2026
When submitting authorization requests for musculoskeletal (MSK) services through Availity Essentials, providers must select 'Surgical' under Service Type instead of 'Medical Injectable' to avoid processing delays. This change became necessary after MSK authorization management transferred from eviCore to Highmark on May 1, 2026.
High impact
Prior Authorization Updates: Two Additions and 90+ Removals
Highmark·Effective Jun 1, 2026
Highmark is adding prior authorization requirements for 2 specialty drug injections (tildrakizumab and cultured chondrocytes) starting September 1, 2026, while removing prior auth requirements for over 90 nuclear medicine procedures, chiropractic services, and one specialty drug starting June 1, 2026. This significantly streamlines authorization requirements for most affected procedures.
Medium impact
[Georgia] Medical Policy and Clinical Guideline Updates:
Anthem BCBS·Effective May 1, 2026
Anthem Blue Cross and Blue Shield (Georgia) has adopted new and/or revised Medical Policies and Clinical Guidelines effective May 1, 2026. The specific policy changes are not detailed in this summary document; the full policy text must be reviewed via the referenced PDF to identify affected billing codes, coverage determinations, and documentation requirements.
Medium impact
[California] Prior authorization requirement changes
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem Medicare Advantage plans in California will require prior authorization for 11 new billing codes related to bone strength analysis, neurostimulator procedures, spinal orthoses, and lower extremity prosthetics. Billing teams must update their systems to request precertification before submitting claims for these services to Medicare Advantage members, or claims will be denied.
Medium impact
[California] Carelon Medical Benefits Management, Inc. code updates
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Carelon Medical Benefits Management will require prior authorization for three breast and wound care procedures: Q4369 (Amnioplast wound repair), 30970T (benign breast tumor laser destruction), and 0971T (malignant breast tumor laser destruction) for Medicare Advantage members in California. Providers must submit prior auth requests through Carelon's provider portal, Availity Essentials, or email before performing these procedures.
Medium impact
[California] Carelon Medical Benefits Management, Inc. updates
Anthem BCBS·Effective Apr 23, 2026
Carelon Medical Benefits Management is updating clinical appropriateness guidelines for Anthem Medicaid effective April 23, 2026, affecting genetic testing, radiology imaging, cardiovascular procedures, sleep disorders, surgical services, and musculoskeletal procedures. Existing prior authorization requirements remain unchanged, and no new prior auth requirements are being implemented at this time; however, practices should monitor for future notices regarding any new or modified authorization requirements.
Medium impact
[California] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·Effective Apr 12, 2026
Anthem Blue Cross California Medicaid has updated 16 medical policies and clinical utilization management guidelines, effective April 12, 2026. These revisions include changes to prior authorization requirements, coverage criteria, and medical necessity determinations for procedures and durable medical equipment (DME). Some services previously covered may now be found non-medically necessary under the new criteria.
High impact
[New York] Specialty pharmacy updates — February 2026
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem is implementing new prior authorization, quantity limit, and step therapy requirements for 14 specialty pharmacy drugs across multiple therapeutic areas. Patients currently receiving these medications without prior authorization will require PA review going forward. Billing teams must identify claims for these drugs and ensure prior authorization is obtained before or concurrent with claim submission to avoid denials.
High impact
[New York] Medical Policy and Clinical Guideline updates
Anthem BCBS·Effective May 1, 2026
Anthem Blue Cross and Blue Shield has revised 3 medical policies and 3 clinical guidelines effective May 1, 2026, which may result in services previously covered now being classified as not medically necessary and/or investigational. Affected areas include IBS biomarker testing, Alzheimer's disease biomarker testing, transcatheter heart valve procedures, neonatal care levels, upper GI endoscopy, and bariatric surgery. Billing teams must review each policy detail to identify which claims may now require prior authorization or face denial.
Medium impact
[New York] Spravato prior authorization requirement
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Spravato (esketamine) requires prior authorization for New York Medicaid Managed Care members when providers obtain it through the 'Buy and Bill' process. Providers must request prior authorization before initiating treatment using the Esketamine (Spravato) Request Form, with InterQual 2025 Esketamine criteria used for review.

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Archive by year

2023 2024 2025 2026

Reimbursement Rate Updates for Radiation Oncology Procedure Codes Effective January 1, 2026

Texas Health and Human Services Commission Notifies Providers of the SFY 2025-29 Financial Compliance Report Information

Provide Records To Support Risk Adjustment Data Validation Audits for Medicare Advantage

Single pharmacy benefit manager update

System issue affecting certain Early Intensive Developmental and Behavioral Intervention (EIDBI) claims resolved

Waiver and AC Resources and MN–ITS Training certificates for May session sent

Early Intensive Developmental and Behavioral Intervention (EIDBI) claim denials for services billed with CPT code H0046 UB resolved

PacificSource Welcomes Community to PACE Open House

Update on H0032 and H0046 reimbursement rates for EIDBI services

[California] 2026 California EAE DSNP Quick Reference Guide

Cancellation of System Maintenance Outage Scheduled for June 5–7, 2026

Subject Information Letter No. 2026-11 ICD10

Men’s mental health: Understanding stigma and encouraging conversations

Assess Childhood and Adolescent Weight and Nutrition and Activity Counseling

New authorization requirements for manual irrigation systems and rectal catheters effective July 1

Avoid This Error When Submitting MSK Authorization Requests

Prior Authorization Updates: Two Additions and 90+ Removals

[Georgia] Medical Policy and Clinical Guideline Updates:

[California] Prior authorization requirement changes

[California] Carelon Medical Benefits Management, Inc. code updates

[California] Carelon Medical Benefits Management, Inc. updates

[California] Medical Policies and Clinical Utilization Management Guidelines update

[New York] Specialty pharmacy updates — February 2026

[New York] Medical Policy and Clinical Guideline updates

[New York] Spravato prior authorization requirement