All Insurance Policy Changes (Page 1339)

Continuing from page 1338. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
[California] New reimbursement policy: Critical Care to Home — Facility
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Anthem will no longer reimburse Critical Care services (CPT 99291, 99292 with revenue code 045X) when a member is treated in the emergency room and discharged home. Billing teams must identify and deny these claims, and providers are prohibited from balance billing members for these non-reimbursable services.
Medium impact
[California] Reimbursement policy update: Multiple Radiology Payment Reduction
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Anthem will expand its Multiple Radiology Payment Reduction policy to include CT scan services for Medicare Advantage members in California. When multiple diagnostic imaging procedures with CMS MPI indicator of 4 are performed by the same provider on the same date of service, only the highest-allowance component will be reimbursed at 100%; additional procedures will receive reduced reimbursement.
Medium impact
[California] Reimbursement policy update: Modifiers 25 and 57: Evaluation and Management with Global Procedures
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Anthem Medicare Advantage in California will no longer reimburse CPT code 99211 (established patient office visit, minimal complexity) when billed with modifier 25. This change affects billing practices for E/M services provided on the same day as procedures. Practices must stop billing 99211 with modifier 25 to Anthem MA plans in California or face claim denials.
High impact
[California] Reimbursement policy update: Preventive Medicine and Sick Visits on the Same Day
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Anthem Medicare Advantage in California will reimburse sick visits at 50% when billed on the same day as preventive/wellness visits (which receive 100% reimbursement), and preventive services at 50% when billed the same day as wellness visits (which receive 100% reimbursement). Billing teams must adjust claim processing and provider education to account for these reduced reimbursement rates for same-day bundled visits.
Medium impact
[California] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Anthem Medicare Advantage plans in California will require prior authorization for 13 newly designated procedures and tests, including respiratory pathogen panels (CPT 0556U, 0563U, 0564U), totally implantable hearing implants (CPT 0951T-0955T), submucosal cryolysis therapy (CPT 0978T-0980T), gait modulation systems (HCPCS E3200), and atidarsagene autotemcel injection (HCPCS J3391). Claims submitted without prior authorization for these codes will be denied.
Low impact
[California] Weight management support for your patients
Anthem BCBS·Identified May 3, 2026
Anthem Blue Cross (California) is promoting the CarelonRx/Lark Weight Management Program as a covered benefit for eligible commercial members. This is an informational bulletin encouraging providers to refer patients to a digital-first weight management program that includes app-based coaching, behavioral health support, and specialized assistance for GLP-1 medication users. No billing code changes, prior authorization requirements, or coverage restrictions are introduced.
Medium impact
[California] Access to care standards
Anthem BCBS·Effective Mar 13, 2026
This is an education and training bulletin establishing mandatory access to care standards for Anthem California providers, including 24/7 availability requirements, specific appointment scheduling timeframes (e.g., urgent within 48-96 hours, routine within 10 business days), after-hours call procedures, and wait time standards. Noncompliance is subject to corrective action plans or contract termination. This policy does not create new billing code changes but establishes operational requirements that affect scheduling, documentation, and compliance monitoring.
Medium impact
[California] Additional information for your 835 electronic remittance advice
Anthem BCBS·Effective Mar 14, 2026
Effective March 14, 2026, Anthem Blue Cross 835 Electronic Remittance Advice (ERA) files will now display both the submitted procedure code and the adjudicated (allowable) procedure code for inclusive (non-separately payable) service lines. This change helps billing teams reconcile claims by identifying which allowable service an inclusive line is bundled into, improving claims reconciliation accuracy.
Medium impact
[California] Electronic Explanations of Payment start mid-July
Anthem BCBS·Effective Jul 15, 2026
Anthem Blue Cross is transitioning from paper Explanations of Payment (EOPs) to electronic delivery via Availity Essentials, effective mid-July 2026. Providers must enroll in electronic remittance options (ERA, Remittance Viewer, or Remittance Inquiry) or request paper copies through specific contact methods. Paper EOPs will no longer be sent automatically.
Medium impact
[California] HEDIS provider resource material now available
Anthem BCBS·Effective Mar 20, 2026
Anthem Blue Cross (California) has made HEDIS provider resource materials available through Availity Payer Spaces for all plan types. These materials include coding guidance, measure-specific information, and documentation support to help providers accurately report quality measures. Billing and clinical teams should access and distribute these resources to improve HEDIS measure compliance and documentation accuracy.
Low impact
[California] Diverse patients and community resources
Anthem BCBS·Effective Mar 25, 2026
This is an educational and informational bulletin from Anthem about cultural competency and health equity resources for providers serving diverse patient populations in California. It does not introduce new billing requirements, coverage changes, or prior authorization mandates—it promotes awareness of existing language support services and provides links to optional training resources.
Medium impact
[California] Submit corrected claims electronically for the Federal Employee Program®
Anthem BCBS·Effective Apr 1, 2026
Anthem Blue Cross (California) now allows Federal Employee Program (FEP) members to submit corrected, replacement, and void/cancel claims electronically through Availity Essentials or EDI, effective April 1, 2026. Billing teams must use specific billing frequency codes (6, 7, 8 for professional claims; 0XX6, 0XX7, 0XX8 for institutional claims) when resubmitting adjudicated claims to ensure proper processing and avoid duplicate claim payment.
Low impact
[California] Medication adherence: a silent epidemic
Anthem BCBS·Identified May 3, 2026
This is an informational provider bulletin from Anthem Blue Cross (California) about medication adherence best practices for chronic disease management. It outlines evidence-based strategies to improve medication adherence rates among Medicare Advantage members, including normalizing adherence conversations, reducing financial barriers, extending days' supply to 90 days, and implementing reminder programs. No billing code changes, prior authorization requirements, or coverage policy modifications are announced.
High impact
[California] Pharmacy NDC Validation
Anthem BCBS·Effective Apr 1, 2026
Anthem Blue Cross (California) is enforcing stricter National Drug Code (NDC) validation requirements for all pharmacy claims submitted to them, effective April 1, 2026. Providers must submit 11-digit NDCs in proper format with correct units of measure (UOM) and quantities on all drug-related professional and outpatient claims. Missing, incorrectly formatted, or mismatched NDCs will delay reimbursement.
Low impact
[California] New Availity Essentials features for out‑of‑network providers
Anthem BCBS·Effective May 1, 2026
Anthem is launching new Availity Essentials platform features in May 2026 that enable out-of-network providers to self-register with Anthem and update demographic information directly through the portal. This streamlines single case agreements, service authorizations, and claims processing without requiring manual provider relations coordination.
High impact
[California] National Drug Codes (NDCs) are required for outpatient claims
Anthem BCBS·Effective Apr 20, 2026
California Medicaid (Medi-Cal) now requires National Drug Codes (NDCs) in 11-digit 5-4-2 format for all outpatient claims that include drug-related services billed with HCPCS drug codes. NDCs must match the actual drug container administered, include proper unit of measure (UOM) codes, and be formatted without hyphens or spaces. Missing, incorrect, or misformatted NDC information will delay claim reimbursement.
Low impact
[California] Elimination of the Suitcase Logo on BCBS Member ID Cards
Anthem BCBS·Identified May 3, 2026
Blue Cross Blue Shield is removing the suitcase logo from California member ID cards and replacing it with product identifiers (e.g., PPO). This is a cosmetic change to card design only—no benefits, network access, or billing processes are affected. Providers may see both old and new card formats during a multi-year rollout.
High impact
[California] Monthly state APL update — Action required
Anthem BCBS·Effective Apr 30, 2026
Anthem has issued six new or updated California state All Plan Letters (APLs) from DHCS and DMHC effective April 30, 2026, covering initial health appointments, mental health/behavioral health services, encounter data quality measures, data-sharing requirements, NCQA accreditation compliance, and COVID-19 testing/immunization delegation. The billing team must review each APL, identify applicable changes to their practice, and implement required procedural updates by stated effective dates to avoid claim denials and processing delays.
Medium impact
[California] EMR alerts aim to close gaps in care for Affordable Care Act members
Anthem BCBS·Effective May 1, 2026
Anthem Blue Cross is implementing EMR alerts to identify care gaps for ACA plan members, requiring providers to review notifications, address documented gaps, and submit claims with high-specificity coding and complete clinical data. This is an informational directive to support proactive care management and ensure compliance with ACA program reporting requirements.
Low impact
[California] Statin Use in Persons with Diabetes: closing the statin gap for adults aged 40 to 75 with diabetes
Anthem BCBS·Effective May 1, 2026
Anthem Blue Cross is emphasizing statin therapy for Medicare Advantage members aged 40-75 with diabetes as part of the SUPD (Statin Use in Persons with Diabetes) Star measure. This is a quality initiative bulletin—not a billing code or coverage change—designed to improve provider awareness and documentation of statin use for cardiovascular risk management in this population.
Medium impact
[California] Anthem expands specialty pharmacy precertification list
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem Medicare Advantage in California is expanding its specialty pharmacy precertification requirements to include 11 new Medicare Part B drugs (primarily denosumab biosimilars, immune globulins, and select oncology/ophthalmology agents). Additionally, step therapy review will be applied to these medications upon precertification initiation. Claims submitted without proper precertification will be denied.
Medium impact
[California] Expansion of Specialty Pharmacy Precertification List
Anthem BCBS·Effective Jun 1, 2026
Effective June 1, 2026, Anthem Medicare Advantage in California is expanding its specialty pharmacy precertification requirements to include 8 new Medicare Part B drugs and implementing step therapy review for Keytruda Qlex and Tecentriq Hybreza. Precertification must be obtained before dispensing these medications, and step therapy will apply as an additional layer of review during precertification initiation. Noncompliance will result in claim denials.
High impact
[California] Claims for XXX procedures billed with an E&M service must use modifier 25
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem Medicare Advantage plans in California will enforce modifier 25 requirements when billing E&M services with XXX procedures. Starting July 1, 2026, claims will be audited to verify the E&M service is significant and separately identifiable from the procedure work. Claims lacking proper documentation may be denied or subject to post-payment review.
High impact
[California] Prior authorization and step therapy updates for medications billed under the medical benefit
Anthem BCBS·Effective Jul 1, 2026
Effective July 1, 2026, Anthem Blue Cross (California Medicaid) is adding 80+ specialty pharmacy medications to its prior authorization requirements when billed under the medical benefit, and implementing step therapy reviews for specific drugs. Providers must now obtain prior authorization before dispensing these medications and include NDC codes on all medical claims for these drugs.
High impact
[New York] Reimbursement policy update: Bundled Services and Supplies — Facility
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Anthem Blue Cross will no longer reimburse separately for blood product splitting, pooling, and thawing services, as well as professional/technical components and supplies for blood product administration and routine ECG when billed with facility or room fees. Facilities must bundle these services into primary service or facility fee reimbursement. Several new codes have been added to the related coding section for reference.

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Archive by year

2023 2024 2025 2026

[California] New reimbursement policy: Critical Care to Home — Facility

[California] Reimbursement policy update: Multiple Radiology Payment Reduction

[California] Reimbursement policy update: Modifiers 25 and 57: Evaluation and Management with Global Procedures

[California] Reimbursement policy update: Preventive Medicine and Sick Visits on the Same Day

[California] Precertification/prior authorization requirement changes

[California] Weight management support for your patients

[California] Access to care standards

[California] Additional information for your 835 electronic remittance advice

[California] Electronic Explanations of Payment start mid-July

[California] HEDIS provider resource material now available

[California] Diverse patients and community resources

[California] Submit corrected claims electronically for the Federal Employee Program®

[California] Medication adherence: a silent epidemic

[California] Pharmacy NDC Validation

[California] New Availity Essentials features for out‑of‑network providers

[California] National Drug Codes (NDCs) are required for outpatient claims

[California] Elimination of the Suitcase Logo on BCBS Member ID Cards

[California] Monthly state APL update — Action required

[California] EMR alerts aim to close gaps in care for Affordable Care Act members

[California] Statin Use in Persons with Diabetes: closing the statin gap for adults aged 40 to 75 with diabetes

[California] Anthem expands specialty pharmacy precertification list

[California] Expansion of Specialty Pharmacy Precertification List

[California] Claims for XXX procedures billed with an E&M service must use modifier 25

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

[New York] Reimbursement policy update: Bundled Services and Supplies — Facility