All Insurance Policy Changes (Page 1343)

Continuing from page 1342. 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
[Virginia] Availity Essentials TMV Quick Reference Guide
Anthem BCBS·Effective Apr 6, 2026
Anthem HealthKeepers Plus (Virginia Medicaid) has launched Total Member View (TMV), a new clinical dashboard within Availity Essentials that replaces the older Patient 360 (P360) system. The TMV provides a 360-degree view of member health history including demographics, care summaries, claims, authorizations, pharmacy data, and care management activities. Billing and clinical staff must request TMV access through their Availity Essentials Administrator and familiarize themselves with the new purple-interface dashboard for member lookups and care coordination.
High impact
[Virginia] National Drug Codes (NDCs) are required for outpatient claims
Anthem BCBS·Effective Apr 17, 2026
Virginia Medicaid (Anthem HealthKeepers) now requires National Drug Codes (NDCs) in 11-digit 5-4-2 format on all outpatient claims that include drug-related services billed with HCPCS drug codes. NDCs must match the actual product administered, be properly formatted with leading zeros, and include correct units of measure (UOM) to avoid claim denials and processing delays.
High impact
[Virginia] Update on long‑term services and supports (LTSS) authorization and care coordination processes
Anthem BCBS·Effective Feb 1, 2026
Virginia Medicaid is implementing a new LTSS (Long-Term Services and Supports) authorization and care coordination process that aligns authorization timelines with LOCERI due dates, effective on staggered regional dates from February through August 2026. Authorization endpoints will now occur 30 days after LOCERI due dates, and providers must collaborate with care managers and participate in Interdisciplinary Care Team meetings before submitting authorization requests. This requires workflow changes to the authorization submission process and mandatory staff training attendance.
Low impact
[Virginia] Elimination of the Suitcase Logo on BCBS Member ID Cards
Anthem BCBS·Identified May 3, 2026
Blue Cross Blue Shield Virginia is removing the suitcase logo from member ID cards and replacing it with product identifiers (such as PPO). This is a cosmetic change to the card design only—member benefits, network access, and eligibility verification processes remain unchanged. The rollout will occur over multiple years, so providers may see both old and new card formats during the transition.
Low impact
[Virginia] 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 emphasizing statin therapy for Medicare Advantage beneficiaries aged 40-75 with diabetes to improve SUPD (Statin Use in Persons with Diabetes) Star measure performance. The bulletin provides clinical guidance and operational strategies for identifying, initiating, and maintaining statin therapy, but does not implement new billing requirements, coverage changes, or prior authorization mandates.
Low impact
[Virginia] Expanding buprenorphine access to improve opioid use disorder outcomes
Anthem BCBS·Identified May 3, 2026
This is an informational provider bulletin from Anthem HealthKeepers (Virginia Medicaid) encouraging expanded use of buprenorphine for opioid use disorder treatment. The policy emphasizes making medication-assisted treatment (MAT) the standard of care, removing administrative barriers, and highlights that DEA X-Waiver requirements were eliminated as of June 27, 2023, allowing any DEA-registered clinician to prescribe buprenorphine. No billing code changes, prior authorization modifications, or coverage restrictions are introduced.
Medium impact
[Virginia] EMR alerts aim to close gaps in care for Affordable Care Act members
Anthem BCBS·Effective May 1, 2026
Anthem Blue Cross and Blue Shield will now send EMR alerts to flag care gaps for ACA plan members, prompting providers to schedule follow-up visits and ensure comprehensive clinical documentation. Billing teams must ensure claims are submitted with highest specificity of coding and all relevant clinical data to support risk adjustment reporting requirements.
Medium impact
[Virginia] Anthem expands specialty pharmacy precertification list
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, Anthem Blue Cross and Blue Shield (Virginia) is expanding its specialty pharmacy precertification requirements for Medicare Advantage plans. Eleven specialty Part B drugs now require prior authorization, and six denosumab biosimilars plus aflibercept and immune globulins will be subject to step therapy review in addition to medical necessity review. Step therapy will not apply to members already receiving these medications.
High impact
[Virginia] Quarterly pharmacy formulary change notice — Cardinal Care Medicaid
Anthem BCBS·Effective May 1, 2026
Anthem HealthKeepers Plus (Virginia Medicaid) is implementing quarterly pharmacy formulary changes effective May 1, 2026, affecting numerous medications across multiple therapeutic classes. Changes include new prior authorization requirements, quantity limits, and dosing edits on drugs including cancer therapies (Keytruda, Inlexzo, Koselugo), diuretics (Lasix Onyu, Ormalvi), endocrine agents, and specialty injectables. Billing teams must review affected medications, update prior authorization workflows, and transition patients to formulary alternatives or obtain PA before the effective date.
High impact
[Virginia] Quarterly pharmacy formulary change notice — FAMIS
Anthem BCBS·Effective May 1, 2026
Anthem HealthKeepers Plus (FAMIS/Virginia Medicaid) is implementing comprehensive quarterly pharmacy formulary changes effective May 1, 2026. Changes include new prior authorization requirements, quantity limits, and preferred/non-preferred status updates for numerous medications across multiple therapeutic classes. Providers must review affected patients and either transition them to formulary alternatives or obtain prior authorization for continued coverage.
High impact
[Virginia] Prior authorization and step therapy updates
Anthem BCBS·Effective May 1, 2026
Effective May 1, 2026, eight specialty pharmacy drugs billed under Virginia Medicaid medical benefits will require prior authorization. Additionally, four immunotherapy drugs (Keytruda, Keytruda Qlex, Tecentriq, and Tecentriq Hybreza) will be subject to new step therapy review requirements upon prior authorization initiation or renewal. Claims must include NDC codes and reference the appropriate Clinical Criteria documents.
High impact
[Virginia] Discontinuation of payment for two immunization administration fees
Anthem BCBS·Effective May 1, 2026
HealthKeepers, Inc. (Medicaid Virginia) is discontinuing payment for immunization administration codes 90460 and 90461 effective May 1, 2026. Billing teams must remove these codes from the fee schedule and redirect claims to alternative administration codes, as serum/vaccine codes remain unaffected.
High impact
[Virginia] Specialty pharmacy updates, March 2026
Anthem BCBS·Effective Jun 1, 2026
Anthem Blue Cross Blue Shield (Virginia) is implementing new prior authorization, quantity limit, and step therapy requirements for 8 specialty pharmacy drugs effective June 1, 2026. Patients currently receiving these medications without prior authorization will require PA requests going forward. Billing teams must identify these drugs by NDC code and Clinical Criteria document number to route claims appropriately.
High impact
[Virginia] Discontinuation of payment for immunization administration fees
Anthem BCBS·Effective Jun 1, 2026
Effective June 1, 2026, HealthKeepers, Inc. (Medicaid in Virginia) will discontinue payment for immunization administration fees for CPT codes 90471, 90472, 90473, and 90474. The practice must stop billing these codes to this payer and implement claim rejection protocols to prevent denials and revenue loss.
High impact
[Virginia] Expansion of specialty pharmacy precertification list
Anthem BCBS·Effective Jun 1, 2026
Effective June 1, 2026, Anthem Blue Cross Blue Shield Virginia is expanding its specialty pharmacy precertification requirements to include 9 new Medicare Part B drugs and implementing step therapy review for pembrolizumab and atezolizumab variants. Billing teams must obtain precertification for these drugs before claims submission, and step therapy will apply to new patients (not current users). Noncompliance will result in claim denials.
Medium impact
[Virginia] Medicaid providers: new PA and step therapy for specialty drugs — action required
Anthem BCBS·Effective Jun 1, 2026
Effective June 1, 2026, Virginia Medicaid (Anthem HealthKeepers) is implementing new prior authorization requirements for six specialty pharmaceutical drugs and adding step therapy review requirements for Nufymco. Billing teams must obtain prior authorization for these drugs on medical claims and include NDC codes for proper processing.
High impact
[Virginia] Claims for XXX procedures billed with an E&M service must use modifier 25
Anthem BCBS·Effective May 1, 2026
Anthem Blue Cross Blue Shield Virginia now requires modifier 25 on all claims for XXX procedures billed with an E&M service, effective May 1, 2026 for claim processing and July 1, 2026 for clinical review. Claims must document that the E&M service is significant and separately identifiable from the procedure work, or face denial or post-payment review.
Medium impact
[Virginia] Expansion of the specialty pharmacy precertification list
Anthem BCBS·Effective Jul 1, 2026
Effective July 1, 2026, Anthem Blue Cross and Blue Shield (Virginia) is expanding its specialty pharmacy precertification list to include five Medicare Part B drugs (Bonscresa, Nufymco, Oziltus, Rybrevant Faspro, and Yartemlea) that now require prior authorization. Additionally, three of these drugs (Bonscresa, Nufymco, and Oziltus) will be subject to step therapy review in addition to medical necessity review.
Medium impact
[Virginia] LTSS providers: Respite authorizations auto‑renew for the new fiscal year; no action needed
Anthem BCBS·Effective Jun 1, 2026
HealthKeepers, Inc. (Virginia Medicaid/Medicare Advantage) will automatically renew all respite care authorizations for active LTSS waiver members in June 2026 for the new fiscal year (July 2026–June 2027). Providers should NOT submit renewal requests; instead, they must report any members lacking respite authorization by June 9, 2026, and immediately notify HealthKeepers of member eligibility changes, benefit changes, or provider changes. New respite authorization forms (DMAS 97 A/B) are only needed when services start for the first time, during personal care renewals, or when switching providers after exhausting the 480-hour annual limit.
Medium impact
[Virginia] C‑SNP verification required for care providers: confirm conditions to prevent member disenrollment
Anthem BCBS·Effective Apr 22, 2026
Anthem Virginia requires care providers to verify C-SNP members' qualifying chronic conditions within five days of outreach to prevent member disenrollment. Verification can be completed verbally or via faxed form, and is separate from SSBCI attestation. Members will be disenrolled effective end of the second month if verification is not received.
High impact
[Virginia] Specialty pharmacy updates for May 2026
Anthem BCBS·Effective Aug 1, 2026
Effective August 1, 2026, Anthem Virginia is implementing prior authorization, quantity limits, step therapy, and site of care requirements for 13 specialty pharmacy medications. Billing teams must update systems to require prior authorization for these drugs before dispensing and verify medical necessity documentation. Patients currently receiving these medications without prior auth will need authorization for continued coverage.
Medium impact
[Virginia] Lenalidomide is now available with end‑to‑end REMS support
Anthem BCBS·Effective May 1, 2026
Lenalidomide is now available through BioPlus Specialty Pharmacy with end-to-end REMS (Risk Evaluation and Mitigation Strategies) support for Virginia commercial plans. BioPlus manages the complete REMS process, reduces administrative burden, and streamlines therapy initiation with a single point of contact and expedited patient enrollment.
High impact
[Georgia] Reimbursement policy update: Screening Services with Related Evaluation and Management Services — Professional
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Anthem Georgia updates its preventive medicine reimbursement policy to prohibit separate billing of screening services, counseling, medical nutrition therapy, prolonged services, visual acuity screenings, gynecological exams, and other E/M services when billed on the same day as a preventive medicine visit (CPT 99381-99387, 99391-99397, G0402). Modifier 25 will not override this bundling restriction. The policy is renamed to reflect this scope.
Medium impact
[Georgia] Reimbursement policy update: Multiple Radiology Payment Reduction
Anthem BCBS·Effective Apr 1, 2026
Effective April 1, 2026, Anthem Medicare Advantage in Georgia will expand its Multiple Radiology Payment Reduction policy to include CT scan services. 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 receives 100% reimbursement; additional procedures are reduced. Billing teams must identify bundled radiology claims and apply appropriate payment reductions.
Medium impact
[Georgia] 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 CPT and HCPCS codes related to tibial nerve stimulators, autografts, and advanced wound care/tissue matrices for Georgia commercial plans. Billing teams must implement prior authorization requirements in their systems and submission workflows for these codes.

Browse by payer Browse by state Browse by specialty Browse by billing code Browse & filter all changes

Get alerts for changes like this

Save a search and receive a daily digest whenever a new policy change matches your filters.

Create a free alert

Archive by year

2023 2024 2025 2026

[Virginia] Availity Essentials TMV Quick Reference Guide

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

[Virginia] Update on long‑term services and supports (LTSS) authorization and care coordination processes

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

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

[Virginia] Expanding buprenorphine access to improve opioid use disorder outcomes

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

[Virginia] Anthem expands specialty pharmacy precertification list

[Virginia] Quarterly pharmacy formulary change notice — Cardinal Care Medicaid

[Virginia] Quarterly pharmacy formulary change notice — FAMIS

[Virginia] Prior authorization and step therapy updates

[Virginia] Discontinuation of payment for two immunization administration fees

[Virginia] Specialty pharmacy updates, March 2026

[Virginia] Discontinuation of payment for immunization administration fees

[Virginia] Expansion of specialty pharmacy precertification list

[Virginia] Medicaid providers: new PA and step therapy for specialty drugs — action required

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

[Virginia] Expansion of the specialty pharmacy precertification list

[Virginia] LTSS providers: Respite authorizations auto‑renew for the new fiscal year; no action needed

[Virginia] C‑SNP verification required for care providers: confirm conditions to prevent member disenrollment

[Virginia] Specialty pharmacy updates for May 2026

[Virginia] Lenalidomide is now available with end‑to‑end REMS support

[Georgia] Reimbursement policy update: Screening Services with Related Evaluation and Management Services — Professional

[Georgia] Reimbursement policy update: Multiple Radiology Payment Reduction

[Georgia] Carelon Medical Benefits Management, Inc. Code Update