All Insurance Policy Changes (Page 1318)

Continuing from page 1317. 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 York] PT and OT fee increase for Commercial products
Anthem BCBS·Effective May 1, 2026
Anthem Blue Cross and Blue Shield is increasing the per diem reimbursement rate for physical therapy (PT) and occupational therapy (OT) services under Commercial plans in New York from $75 to $85, effective May 1, 2026. This applies to HMO, EPO, PPO, Blue Access, Connection, and Indemnity products. Billing teams should update fee schedules and systems to reflect the new rate to avoid underbilling.
Medium impact
[New York] Reimbursement policy update: Outpatient Facility Revenue Code Billing Requirements — Facility
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem Blue Cross and Blue Shield is adding revenue code 0300 (Laboratory – General) to the Related Coding section of the Outpatient Facility Revenue Code Billing Requirements policy for New York. Facilities must now report current and valid CPT or HCPCS codes alongside this revenue code in accordance with NUBC guidelines.
High impact
[New York] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Anthem BCBS·Effective Apr 4, 2026
Carelon Medical Benefits Management updated clinical appropriateness guidelines effective April 4, 2026 across radiology, oncologic imaging, radiation oncology, genetic testing, and rehabilitative services for Medicare Advantage and Medicaid plans. Changes include removal of certain imaging requirements (pediatric SBO radiographs, sports hernia imaging), alignment with ACR and NCCN guidelines, expanded cancer screening and treatment indications, new hereditary cancer syndrome criteria, and addition of specific billing codes for genetic testing (81218, 81310, 81334, 81338, 81339, 81345).
Medium impact
[Ohio] Carelon Medical Benefits Management, Inc. code updates
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, three specific surgical procedure codes (Q4369, 30970T, and 0971T) will require prior authorization through Carelon Medical Benefits Management for Ohio Medicare Advantage members. Providers must submit prior auth requests via the Carelon provider portal, Availity Essentials, or email before performing these procedures to avoid claim denials.
Medium impact
[Ohio] Reimbursement policy update: Outpatient Facility Revenue Code Billing Requirements — Facility
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem Blue Cross and Blue Shield is adding revenue code 0300 (Laboratory – General) to the Related Coding section of the Outpatient Facility Revenue Code Billing Requirements policy for Ohio. Facilities must now report current and valid CPT or HCPCS codes alongside this revenue code in accordance with NUBC guidelines. This is a billing requirement change with no impact on member care or balance billing restrictions.
Medium impact
[Ohio] Specialty pharmacy updates — February 2026
Anthem BCBS·Effective May 1, 2026
Anthem Ohio is implementing new prior authorization, quantity limit, and step therapy requirements for 14 specialty pharmacy drugs effective May 1, 2026. Practices must begin requesting prior authorization for these medications on dates of service after May 1, 2026, and include NDC codes on claims to expedite processing. Patients currently receiving these medications without prior authorization will require authorization going forward to avoid claim denials.
Medium impact
[Ohio] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·Effective Apr 20, 2026
Anthem Medicaid in Ohio is updating Medical Policies and Clinical Utilization Management Guidelines effective April 20, 2026. Three policies have been revised or reviewed: External Upper Limb Stimulation for Tremors (new DME policy), Dichoptic Digital Therapy for Amblyopia (revised), and Cryosurgical/Radiofrequency/Microwave/Percutaneous Ethanol Ablation for liver tumors (revised with title change). Some previously covered services may now require additional medical necessity documentation or may be denied.
Medium impact
[Ohio] Clinical Criteria updates
Anthem BCBS·Effective Apr 4, 2026
Anthem has revised clinical criteria for 17 existing medical drug benefit policies and added 3 new policies effective April 4, 2026. These changes affect medical necessity requirements and coding edits for specialized medications including oncology agents, immunology drugs, and rare disease treatments. The billing team must access updated clinical criteria documentation to ensure claims comply with new or modified medical necessity requirements.
Medium impact
[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Anthem BCBS·Effective Apr 4, 2026
Carelon Medical Benefits Management updated clinical appropriateness guidelines for oncologic imaging, genetic testing, and hereditary cancer syndromes effective April 4, 2026 for Ohio Medicaid and MyCare plans. Multiple guidelines now align with NCCN standards, affecting cancer screening, diagnostic imaging, and genetic testing coverage criteria. Six new genetic testing CPT codes (81218, 81310, 81334, 81338, 81339, 81345) were added, and specific hereditary syndromes and cancer types have expanded or new indications.
Medium impact
[Virginia] Precertification/prior authorization list change notification
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem Blue Cross Blue Shield Virginia is adding four new services to its precertification/prior authorization requirement list: PFAS testing (0589U), electrical stimulation devices (E0765), allogeneic bone marrow-derived mesenchymal stromal cell therapy (J3402), and encapsulated cell therapy for degenerative ocular disease (J3403). Providers must obtain prior authorization before delivering these services or claims may be denied for ineligibility.
Medium impact
[Virginia] Carelon Medical Benefits Management, Inc. code updates
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Carelon Medical Benefits Management is adding three surgical procedure codes (Q4369, 30970T, 0971T) to its prior authorization requirements for Medicare Advantage plans in Virginia. Billing teams must implement prior authorization verification for these codes before the effective date to prevent claim denials.
High impact
[Virginia] Specialty pharmacy updates — February 2026
Anthem BCBS·Effective May 1, 2026
Anthem Blue Cross Blue Shield (Virginia) is implementing new prior authorization, quantity limit, and step therapy requirements for 13 specialty pharmacy drugs effective May 1, 2026. Patients currently receiving these medications without prior authorization will require PA review going forward. Billing teams must update systems to request prior authorization for these specialty drugs and include NDC codes on claims to expedite processing.
Medium impact
[Virginia] Carelon Medical Benefits Management, Inc. updates
Anthem BCBS·Effective Apr 23, 2026
Carelon Medical Benefits Management has updated clinical appropriateness guidelines for HealthKeepers, Inc. (Virginia Medicaid) effective April 23, 2026. Updates include new guidelines for Genetic Testing and Hereditary Cancer Testing. No new prior authorization requirements are being implemented at this time, though providers should monitor for future notices if prior auth is added.
High impact
[Virginia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Anthem BCBS·Effective Apr 4, 2026
Carelon Medical Benefits Management has updated clinical appropriateness guidelines for Virginia Medicare Advantage members, effective April 4, 2026. Changes include simplified imaging criteria across radiology, oncology, and genetics testing; expanded coverage for advanced cancer treatments and genetic testing; and clarifications for radiation therapy, theranostics, and rehabilitative services. Billing and clinical teams must review updates in their respective specialty areas and ensure prior authorization requests reflect new guidelines.
High impact
[Georgia] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·Effective May 14, 2026
Anthem Georgia updated multiple medical policies and clinical utilization management guidelines effective May 14, 2026, including revisions to prior authorization requirements, coverage criteria, and medical necessity standards for services such as gene therapy, surgical procedures, durable medical equipment, and diagnostic testing. Some previously covered services may now be found not medically necessary under the revised criteria.
Medium impact
[Georgia] Specialty pharmacy updates — February 2026
Anthem BCBS·Effective May 1, 2026
Anthem Georgia is implementing new prior authorization, quantity limit, and step therapy requirements for 14 specialty pharmacy medications effective May 1, 2026. Patients currently receiving these medications without prior authorization will require PA requests going forward. NDC codes should be included on claims to expedite processing of drugs billed with NOC codes.
Medium impact
[Georgia] Precertification/prior authorization requirement changes
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem Medicare Advantage in Georgia is adding prior authorization requirements for 12 specific billing codes related to bone strength/fracture risk analysis (CPT codes 0554T-0558T, G0130), cell therapies (J3402-J3403), and orthopedic devices (L1499, L5657). All services under these codes will require precertification before billing to Medicare Advantage members to avoid claim denials.
Medium impact
[Georgia] Precertification/prior authorization list change notification
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem Blue Cross Blue Shield Georgia is adding four new services to its precertification/prior authorization requirement list for 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 update systems to require prior authorization for these codes before claims are submitted.
Medium impact
[Georgia] 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 specific surgical codes (Q4369, 30970T, 0971T) related to wound repair and breast tumor destruction procedures for Georgia Medicare Advantage members. Billing teams must implement prior authorization requirements in their systems and provider workflows before the effective date.
Medium impact
[Georgia] Reimbursement policy update: Outpatient Facility Revenue Code Billing Requirements — Facility
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem Georgia is adding revenue code 0300 (Laboratory – General) to the Related Coding section of the Outpatient Facility Revenue Code Billing Requirements policy. Facilities must now report current and valid CPT or HCPCS codes alongside this revenue code in accordance with NUBC guidelines.
Medium impact
[Georgia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Anthem BCBS·Effective Apr 4, 2026
Carelon Medical Benefits Management updated clinical appropriateness guidelines effective April 4, 2026, affecting radiology imaging protocols, oncologic imaging, radiation oncology, genetic testing, and rehabilitative services for Medicare Advantage plans in Georgia. Changes include alignment with ACR and NCCN criteria, removal of certain indications (e.g., sports hernia imaging), expanded cancer screening/treatment criteria, new genetic testing indications, and clarification of specific imaging requirements. Billing teams must review updates to prior authorization requirements and ensure documentation aligns with new clinical criteria.
Medium impact
[Georgia] Clinical Criteria updates
Anthem BCBS·Effective Apr 4, 2026
Anthem has updated clinical criteria for 23 medications and biologics used in medical drug benefits, effective April 4, 2026. Of these, 20 are revisions to existing criteria (CC-0002 through CC-0276) and 3 are newly published criteria (CC-0294, CC-0295, CC-0296). The billing team must verify whether any of these revised or new criteria affect prior authorization requirements, medical necessity documentation, or coverage determinations for claims submitted under Anthem Medicare Advantage plans in Georgia.
Low impact
The Capital Region Comes Together for 518 Day
CDPHP·Identified May 18, 2026
This is a community service announcement from CDPHP about a regional volunteer day (518 Day) and fundraising events. This is NOT an insurance policy change and contains no billing, coverage, documentation, coding, or reimbursement modifications that would affect medical billing operations.
Low impact
Mental Health Is Health: Practical Support for Our Community
PacificSource Health Plans·Identified May 18, 2026
This is a community awareness and advocacy message from PacificSource emphasizing mental health as integral to overall healthcare. It does not introduce billing changes, new coverage policies, prior authorization requirements, or specific clinical guidance that would affect claims processing or billing workflows.
Medium impact
Directed pharmacy dispensing payment update
Minnesota Medicaid (MHCP)·Effective Aug 1, 2026
Minnesota MCOs will provide a new $4.50 per-prescription directed dispensing payment to eligible outpatient pharmacies starting August 2026. Pharmacies must complete and submit the Directed Pharmacy Dispensing Payment Assurance Statement (DHS-8750) by July 24, 2026, to qualify. Eligibility requires MHCP provider enrollment, Minnesota location, independence from pharmacy benefit managers/health carriers, and either location in a medically underserved area OR no more than 13 Minnesota locations.

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Archive by year

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[New York] PT and OT fee increase for Commercial products

[New York] Reimbursement policy update: Outpatient Facility Revenue Code Billing Requirements — Facility

[New York] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

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

[Ohio] Reimbursement policy update: Outpatient Facility Revenue Code Billing Requirements — Facility

[Ohio] Specialty pharmacy updates — February 2026

[Ohio] Medical Policies and Clinical Utilization Management Guidelines update

[Ohio] Clinical Criteria updates

[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

[Virginia] Precertification/prior authorization list change notification

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

[Virginia] Specialty pharmacy updates — February 2026

[Virginia] Carelon Medical Benefits Management, Inc. updates

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

[Georgia] Medical Policies and Clinical Utilization Management Guidelines update

[Georgia] Specialty pharmacy updates — February 2026

[Georgia] Precertification/prior authorization requirement changes

[Georgia] Precertification/prior authorization list change notification

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

[Georgia] Reimbursement policy update: Outpatient Facility Revenue Code Billing Requirements — Facility

[Georgia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

[Georgia] Clinical Criteria updates

The Capital Region Comes Together for 518 Day

Mental Health Is Health: Practical Support for Our Community

Directed pharmacy dispensing payment update