All Insurance Policy Changes (Page 1340)

Continuing from page 1339. 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
[New York] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility policy
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Anthem will no longer reimburse professional services billed on UB-04 forms in New York. Outpatient claims must now use modifiers PN, PO, or ER to indicate service location, with off-campus non-contracted locations receiving reduced reimbursement at 40% of allowable.
Medium impact
[New York] 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 plans in New York will no longer reimburse CPT code 99211 when billed with modifier 25. This change restricts separate payment for minimal E/M services performed on the same day as another procedure, even when modifier 25 is used to indicate a significant, separately identifiable service.
High impact
[New York] 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 plans in New York will reimburse sick visits and preventive services performed on the same day at 50% of the applicable fee schedule or contracted rate, rather than at full reimbursement. Billing teams must adjust claim submission logic and provider documentation to account for this bundling reduction when preventive and sick visit services occur on the same date of service.
High impact
[New York] Expanding Site of Care Program for musculoskeletal and surgical procedures
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Anthem is expanding its Site of Care Program to require musculoskeletal and surgical procedures be performed in appropriate settings (ASCs or outpatient facilities rather than hospital outpatient departments). Precertification is now required for procedures scheduled at outpatient hospital settings to ensure clinical appropriateness. Billing teams must implement prior authorization workflows for affected MSK and surgical procedures.
Medium impact
[New York] Carelon Medical Benefits Management, Inc. Code Update
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Carelon Medical Benefits Management will require prior authorization for 30 specific HCPCS and CPT codes related to tibial nerve stimulators, autografts, and advanced wound care matrices. Billing teams must implement prior authorization workflows for these codes in their system and ensure providers submit requests through Carelon's ProviderPortal or Availity before delivering these supplies and services.
High impact
[New York] 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 with revenue code 045X) when a member is treated in the emergency room and discharged home. Critical Care services remain reimbursable only if the member requires inpatient admission, trauma, or observation services. Providers may not balance bill members for these non-reimbursable claims.
High impact
[New York] Clinical Criteria updates
Anthem BCBS·Effective Mar 22, 2026
Anthem has updated clinical criteria for 47 medical drug benefit policies effective March 22, 2026, including 2 newly published criteria (Forzinity and Inlexzo) and 45 revised criteria affecting immunologic, oncologic, hematologic, and other specialty drugs. These changes apply to medical plan drug benefits only (not pharmacy services) and may affect prior authorization requirements, medical necessity documentation, and billing for affected drug therapies.
Medium impact
[New York] Physician access and appointment availability standards
Anthem BCBS·Effective Apr 1, 2026
Anthem Blue Cross and Blue Shield (New York) has established physician access and appointment availability standards effective April 1, 2026. PCPs must provide 24/7 member access with live person contact within 2 calls, arrange comparable back-up coverage, and meet specific appointment scheduling windows (routine within 4 weeks, urgent within 24 hours, emergency within 2 hours). Non-compliance with these operational standards may affect network participation and member satisfaction audits.
Low impact
[New York] New Availity Essentials features for out‑of‑network providers
Anthem BCBS·Effective May 1, 2026
Anthem is launching new self-service features in Availity Essentials for out-of-network providers starting May 2026. Out-of-network providers can now register directly through the platform and manage demographic updates, which should streamline single case agreements, service authorizations, and claims processing.
Medium impact
[New York] Reminder: state mandate — behavioral health appointment wait times
Anthem BCBS·Effective Apr 1, 2026
New York State Medicaid now requires behavioral health providers to meet specific appointment wait time standards (10 business days for initial outpatient appointments, 7 calendar days post-discharge) and attest annually to compliance through Availity Essentials. Billing teams must ensure contracted behavioral health providers have completed this attestation to maintain network participation and avoid claim issues.
High impact
[New York] Outpatient facility claims update: modifier 26 (professional services) on UB‑04
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Anthem will no longer provide separate facility reimbursement for outpatient facility claims that include modifier 26 (professional services). This aligns with Anthem's Facility Guidelines for Claims Related to Professional Services policy. Billing teams must stop expecting dual reimbursement (facility + professional) for lines billed with modifier 26 on UB-04 claims.
Medium impact
[New York] New benefit launching: home sleep studies
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Medicaid and HARP members age 18+ in New York can now access home sleep studies as a medically appropriate alternative to lab-based sleep studies. Providers determine medical necessity and appropriateness on a case-by-case basis. Billing teams must be prepared to process claims for this newly covered diagnostic service.
High impact
[New York] National Drug Codes (NDCs) are required for outpatient claims
Anthem BCBS·Effective Apr 17, 2026
New York Medicaid now requires National Drug Codes (NDCs) in 11-digit 5-4-2 format for all outpatient claims with drug-related services billed using HCPCS codes. NDCs must match the actual product administered, include proper unit of measure (ML, UN, GR, F2), and be submitted without hyphens or spaces. Incorrect or missing NDC information will delay reimbursement.
Low impact
[New York] 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 member ID cards and replacing it with product identifiers (e.g., PPO). This is a cosmetic change only—no benefits, coverage, or network access are affected. Providers will see cards with and without the logo during a multi-year rollout.
Medium impact
[New York] EMR alerts aim to close gaps in care for Affordable Care Act members
Anthem BCBS·Effective May 1, 2026
Anthem is implementing EMR alerts to identify care gaps for ACA plan members, requiring providers to review notifications, schedule follow-up visits, and submit claims with complete clinical documentation and specific coding to support risk adjustment reporting compliance.
Low impact
[New York] Refer eligible members to our doula network
Anthem BCBS·Effective May 1, 2026
Anthem Blue Cross is launching a doula services network for eligible New York Medicaid members, effective May 1, 2026. Providers should refer eligible members for non-clinical support during pregnancy, labor, delivery, and postpartum care through the online portal or care management team. This is an informational policy about a new benefit availability, not a billing code or coverage change.
Low impact
[New York] Statin Use in Persons with Diabetes: closing the statin gap for adults aged 40 to 75 with diabetes
Anthem BCBS·Effective May 1, 2026
This is an informational provider bulletin from Anthem Blue Cross Blue Shield regarding statin therapy for Medicare Advantage members aged 40-75 with diabetes. The policy emphasizes closing gaps in statin utilization through identification, initiation, intensification, and improved adherence to align with ADA/ACC/AHA guidelines and improve SUPD (Statin Use in Persons with Diabetes) Star measure performance. No billing code changes or prior authorization requirements are introduced.
High impact
[New York] Quarterly pharmacy formulary change notice
Anthem BCBS·Effective May 1, 2026
Anthem New York Medicaid is implementing quarterly pharmacy formulary changes effective May 1, 2026, affecting multiple drug classes. Changes include preferred/non-preferred status revisions, new prior authorization requirements, and quantity limit (QL) edits on numerous medications across antihistamines, anticoagulants, oncology agents, dermatologicals, and other therapeutic classes. Billing teams must identify affected patients, transition to formulary alternatives where clinically appropriate, and obtain prior authorizations for non-compliant medications to avoid claim denials.
Medium impact
[New York] Anthem expands specialty pharmacy precertification list
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem is expanding its specialty pharmacy precertification requirements for Medicare Advantage members in New York. Eleven specialty Part B drugs now require prior authorization, and nine denosumab/immune globulin products are subject to new step therapy requirements under specific clinical guidelines.
High impact
[New York] Use JW and JZ modifiers correctly for drug waste and full‑dose billing
Anthem BCBS·Effective Jun 1, 2026
Effective June 1, 2026, Anthem Commercial plans in New York are requiring revised claim submission for single-dose vials to align with Medicare standards. Providers must now submit two separate claim lines when drug waste occurs: one line showing quantity administered (no modifier) and a second line showing discarded amount (JW modifier). When no waste occurs, submit a single line with JZ modifier. This change affects how pharmaceutical waste is billed and reimbursed.
High impact
[New York] Expansion of specialty pharmacy precertification list
Anthem BCBS·Effective Jun 1, 2026
Effective June 1, 2026, Anthem Medicare Advantage in New York is expanding its specialty pharmacy precertification requirements to include 9 new Part B drugs and implementing step therapy for Keytruda Qlex and Tecentriq Hybreza. All claims for these medications without proper precertification and step therapy compliance will be deemed ineligible for reimbursement.
High impact
[New York] Specialty pharmacy updates, March 2026
Anthem BCBS·Effective Jun 1, 2026
Anthem is implementing new prior authorization, quantity limit, and step therapy requirements for 8 specialty pharmacy drugs effective June 1, 2026. Billing teams must update systems to require prior authorization for non-oncology specialty drugs managed by Anthem and oncology drugs managed by Carelon, and enforce quantity limits and step therapy edits on specified medications. Patients currently receiving these medications without prior auth may face coverage changes.
Medium impact
[New York] Prior authorization and step therapy updates
Anthem BCBS·Effective Jun 1, 2026
Effective June 1, 2026, six specialty pharmacy medications billed on medical claims now require prior authorization under New York Medicaid. Additionally, two of these drugs (Lerochol and Nufymco) are subject to new step therapy requirements that will be applied during prior authorization initiation or renewal.
Medium impact
[New York] Expansion of the specialty pharmacy precertification list
Anthem BCBS·Effective Jul 1, 2026
Effective July 1, 2026, Anthem Medicare Advantage in New York is adding five specialty pharmacy drugs to its precertification review process and implementing step therapy requirements for three of those drugs. Billing teams must obtain prior authorization for these Part B medications before dispensing, and step therapy will apply to new patients (but not those already receiving these medications).
High impact
[New York] 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 New York will require modifier 25 on all claims billing XXX procedures with E&M services. Starting July 1, 2026, claims will be audited to verify the E&M service is significant and separately identifiable from the procedure work. Claims without proper modifier 25 or supporting documentation may be denied or subject to post-payment review.

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Archive by year

2023 2024 2025 2026

[New York] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility policy

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

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

[New York] Expanding Site of Care Program for musculoskeletal and surgical procedures

[New York] Carelon Medical Benefits Management, Inc. Code Update

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

[New York] Clinical Criteria updates

[New York] Physician access and appointment availability standards

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

[New York] Reminder: state mandate — behavioral health appointment wait times

[New York] Outpatient facility claims update: modifier 26 (professional services) on UB‑04

[New York] New benefit launching: home sleep studies

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

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

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

[New York] Refer eligible members to our doula network

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

[New York] Quarterly pharmacy formulary change notice

[New York] Anthem expands specialty pharmacy precertification list

[New York] Use JW and JZ modifiers correctly for drug waste and full‑dose billing

[New York] Expansion of specialty pharmacy precertification list

[New York] Specialty pharmacy updates, March 2026

[New York] Prior authorization and step therapy updates

[New York] Expansion of the specialty pharmacy precertification list

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