All Insurance Policy Changes (Page 1351)

Continuing from page 1350. 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
Update to our interactive voice response (IVR) phone system
Cigna·Effective Apr 16, 2026
Cigna Healthcare has updated their IVR phone system to automatically disconnect callers who cannot provide required information (TIN, call reason, or member ID). This change aims to reduce bot calls and wait times for legitimate provider calls.
High impact
MSK Authorization Transition on May 1; Your Questions Answered
Highmark·Effective May 1, 2026
Effective May 1, 2026, Highmark will directly manage all musculoskeletal (MSK) and interventional pain management (IPM) prior authorization requests, transitioning away from eviCore. Over 100 MSK surgical procedure codes are being added to site of care clinical review requirements as part of this transition.
Medium impact
2026-04-15 - Overview of the CMS Interoperability Standards & Prior Authorization for Drugs Proposed Rule Webinar – April 16
Medicare/CMS·Identified Apr 16, 2026
CMS is hosting a webinar on April 16 to discuss a new proposed rule (CMS-0062-P) that would require electronic prior authorization for drugs, improve decision timeliness, and increase transparency in the drug prior authorization process. This is currently a proposed rule being discussed, not yet implemented policy.
High impact
2026-04-16 - CMS Launches First Wave of HealthTech Ecosystem Tools, Fast-Tracking a Fully Digital, Patient-Centered Health System
Medicare/CMS·Effective May 11, 2026
CMS launched new digital health tools and requires providers to enroll third-party vendors for Medicare eligibility checking by May 11. Multiple billing updates include new ASC payment codes, hospital billing processes, and therapeutic shoe documentation requirements.
Medium impact
There is a delay in processing provider enrollment requests
Minnesota Medicaid (MHCP)·Identified Apr 16, 2026
The Minnesota Department of Human Services is experiencing a backlog in processing provider enrollment requests (new enrollments, re-enrollments, and enrollment updates) due to a statewide provider revalidation initiative for high-risk services. Processing times will exceed the standard 30-day timeframe until the revalidation effort is completed by May 31, 2026.
Low impact
New Functionality in Predictal: Manage Your Pre-Auth Notification Contact Details
Highmark·Effective Apr 17, 2026
Highmark's Predictal Auth Automation Hub now allows providers to specify custom phone, fax, and mailing addresses for pre-authorization notifications on each individual submission. This feature is particularly beneficial for large facilities that need notifications sent to different departments or locations within their organization.
Medium impact
Cigna Specialty Care Options programs: Changes to the drug list
Cigna·Effective Mar 9, 2026
Cigna has expanded its Specialty Care Options programs to include additional specialty medical injectables that require site-of-care review to determine if lower-intensity settings are clinically appropriate. Most hemophilia clotting factors become effective July 1, 2026, while some immune globulin and oncology medications have earlier effective dates.
Medium impact
2026-04-13 - Hospital Inpatient Prospective Payment System & Long-Term Care Hospital Prospective Payment System Proposed Rule: FY 2027
Medicare/CMS·Effective Oct 1, 2026
CMS proposed a 2.4% increase in Medicare inpatient hospital payment rates for FY 2027, effective October 1, 2026. The rule also proposes new prior authorization timelines for drugs: 24 hours for urgent requests and 72 hours for standard requests, with increased transparency requirements for claim denials.
Medium impact
Public Comment Period for Proposed EVV Rule Updates
Texas Medicaid·Identified Apr 13, 2026
Texas Health and Human Services Commission is accepting public comments on proposed Electronic Visit Verification (EVV) rule updates through May 4, 2026. This affects home health and personal care services that require EVV compliance for Medicaid reimbursement.
Low impact
Deadline for Comments on Proposed Rules Due May 4
Texas Medicaid·Identified Apr 13, 2026
Texas Health and Human Services Commission is accepting public comments on proposed rules for the Interagency Reportable Conduct Search Engine affecting multiple chapters of Texas Administrative Code. The comment period closes May 4, 2026, and stakeholders can submit feedback via email.
Medium impact
LTC FFS Claim Processing/Payment Timeline
Texas Medicaid·Identified Apr 13, 2026
TMHP has published a new Long-Term Care Fee-for-Service claim processing and payment timeline for Texas Medicaid providers. The timeline outlines the complete process for LTC FFS claims submitted to TMHP and is available on their reference material webpages.
Medium impact
May 2026 TMPPM Update for Immunosuppressive Drugs
Texas Medicaid·Effective May 1, 2026
Texas Medicaid is adding coverage for Mycophenolate mofetil (HCPCS code J7528) to the Immunosuppressive Drugs section, effective May 1, 2026. This drug is used to prevent organ rejection in kidney, liver, and heart transplant patients.
Medium impact
Expanded Drug List and New Prior Authorizations for HTW Effective July 1, 2026
Texas Medicaid·Effective Jul 1, 2026
Starting July 1, 2026, Texas Medicaid's Healthy Texas Women (HTW) program will expand drug coverage to include all Medicaid-eligible drugs in currently covered health categories, applying the same prior authorization and preferred drug list rules as regular Medicaid. This change aligns HTW with federal Medicaid requirements as the program transitions from state to federal funding.
Medium impact
May 2026 TMPPM Update for Colony Stimulating Factors
Texas Medicaid·Effective May 1, 2026
Texas Medicaid will add filgrastim-txid (Nypozi) with procedure code Q5148 to their covered colony stimulating factors effective May 1, 2026. This biosimilar drug will be covered alongside existing filgrastim and pegfilgrastim options.
Low impact
Critical Incident Management System Monthly Provider Demonstrations
Texas Medicaid·Effective Apr 14, 2026
Texas Health and Human Services Commission is offering monthly provider demonstration webinars for the Critical Incident Management System (CIMS) starting April 14, 2026. This training applies to CLASS, DBMD, HCS, TxHmL providers and LIDDAs who have CIMS access.
Medium impact
Expanded in-network kidney care with Fresenius Medical Care effective January 1, 2026
Cigna·Effective Jan 1, 2026
Effective January 1, 2026, Cigna Healthcare expanded in-network coverage for kidney care through partnership with Fresenius Medical Care, providing access to over 2,600 dialysis centers nationwide and 2,300 nephrologists in select regions. This gives patients broader in-network options for dialysis, nephrology services, and comprehensive renal care teams.
Medium impact
Adoption of LOCUS and CALOCUS-CASII criteria in Colorado
Cigna·Effective Apr 11, 2026
Effective April 11, 2026, Evernorth Behavioral Health will adopt LOCUS criteria for patients 19+ and CALOCUS-CASII criteria for patients 6-18 when conducting mental health level-of-care medical necessity reviews in Colorado. This replaces previous criteria but does not change the medical necessity review process itself.
Medium impact
Specialty Medical Injectables with Reimbursement Restriction: List updates
Cigna·Effective Mar 30, 2026
Cigna Healthcare has added Loargys® (pegzeilarginase-nbln) to their Specialty Medical Injectables with Reimbursement Restriction list effective March 30, 2026. This drug must now be dispensed by a Cigna-contracted specialty pharmacy and claims must be submitted through that pharmacy unless otherwise authorized.
High impact
GHP Family notice to home health agencies and caregivers
Geisinger Health Plan·Identified Apr 13, 2026
Unable to analyze this policy. The provided content is a CAPTCHA/bot-verification error page from Geisinger's website, not the actual policy document. The real policy content about GHP Family notice to home health agencies and caregivers could not be retrieved due to access restrictions.
High impact
Medical and Clinical Policy Updates - Effective July 1, 2026
Sentara Health Plans·Effective Jul 1, 2026
Sentara Health Plans has updated 53 medical policies effective July 1, 2026, affecting surgical procedures, durable medical equipment, behavioral health/substance abuse treatment, cardiac rehabilitation, and other services. Most policies were reviewed for continued applicability; several were revised (including gastrointestinal procedures, BPH treatments, prescription digital therapeutics, wheelchairs, chiropractic services, and ambulatory devices). One policy (TIPSS) was archived and will no longer be covered. Billing teams must verify coverage requirements and prior authorization rules for affected services before the effective date.
Low impact
Agenda for April 24, 2026, DUR Board Meeting Now Available
Texas Medicaid·Effective Apr 24, 2026
The Texas Drug Utilization Review (DUR) Board will meet on April 24, 2026, to review outpatient prescription drugs for Texas Medicaid and update the preferred drug list. This is an informational notice about the meeting agenda availability, not a policy change affecting billing procedures.
Low impact
ICF Quarterly Webinar with HHSC LTCR
Texas Medicaid·Effective Apr 15, 2026
HHSC Long-term Care Regulation is hosting a quarterly webinar for ICF and IID providers on April 15, 2026, from 2-3 p.m. to share the latest information from LTCR. This is an educational opportunity for providers in the long-term care space.
Medium impact
New tool to improve transparency into claim offsets and balances
Cigna·Effective Apr 8, 2026
Cigna Healthcare has launched a new Negative Balance Report (NBR) tool on their provider portal to give billing teams better visibility into claim offsets and overpayment balances. This tool allows providers to track when claims have been offset against future payments and monitor remaining balances from overpaid claims.
Medium impact
2026-04-09 - Skilled Nursing Facility Prospective Payment System Proposed Rule: FY 2027
Medicare/CMS·Identified Apr 9, 2026
CMS issued proposed rules for FY 2027 payment updates across multiple post-acute care settings, with SNF rates increasing 2.4%, IRF rates increasing 2.4%, IPF rates increasing 2.3%, and hospice rates increasing 2.4%. These are proposed rules with comments due June 1, 2026, and final rates will be determined later.
High impact
May 2026 Community Solutions (Medicaid) formulary and coverage policies notification
PacificSource Health Plans·Effective May 15, 2026
PacificSource Community Solutions (Medicaid) has removed 5 medications from formulary effective May 15, 2026 (Zostavax, Fycompa, Mavenciad, Bonjesta 20-20mg, Saxenda) and updated quantity limits for 5 medications including Freestyle Libre sensors and Yorvipath. Billing teams must immediately identify affected claims and implement prior authorization and coverage denials to prevent payment processing errors.

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

Update to our interactive voice response (IVR) phone system

MSK Authorization Transition on May 1; Your Questions Answered

2026-04-15 - Overview of the CMS Interoperability Standards & Prior Authorization for Drugs Proposed Rule Webinar – April 16

2026-04-16 - CMS Launches First Wave of HealthTech Ecosystem Tools, Fast-Tracking a Fully Digital, Patient-Centered Health System

There is a delay in processing provider enrollment requests

New Functionality in Predictal: Manage Your Pre-Auth Notification Contact Details

Cigna Specialty Care Options programs: Changes to the drug list

2026-04-13 - Hospital Inpatient Prospective Payment System & Long-Term Care Hospital Prospective Payment System Proposed Rule: FY 2027

Public Comment Period for Proposed EVV Rule Updates

Deadline for Comments on Proposed Rules Due May 4

LTC FFS Claim Processing/Payment Timeline

May 2026 TMPPM Update for Immunosuppressive Drugs

Expanded Drug List and New Prior Authorizations for HTW Effective July 1, 2026

May 2026 TMPPM Update for Colony Stimulating Factors

Critical Incident Management System Monthly Provider Demonstrations

Expanded in-network kidney care with Fresenius Medical Care effective January 1, 2026

Adoption of LOCUS and CALOCUS-CASII criteria in Colorado

Specialty Medical Injectables with Reimbursement Restriction: List updates

GHP Family notice to home health agencies and caregivers

Medical and Clinical Policy Updates - Effective July 1, 2026

Agenda for April 24, 2026, DUR Board Meeting Now Available

ICF Quarterly Webinar with HHSC LTCR

New tool to improve transparency into claim offsets and balances

2026-04-09 - Skilled Nursing Facility Prospective Payment System Proposed Rule: FY 2027

May 2026 Community Solutions (Medicaid) formulary and coverage policies notification