All Insurance Policy Changes (Page 1381)

Continuing from page 1380. 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
Medicaid Peer delivered services policy update
PacificSource Health Plans·Effective Jan 1, 2026
PacificSource Medicaid is updating its peer-delivered services policy effective January 1, 2026. Providers billing more than 8 units of peer-delivered services must now submit clinical documentation with claims to establish medical necessity and appropriateness. Claims exceeding 8 units submitted without documentation will be denied.
Medium impact
2026 NUBC/UB04 Changes
Arkansas Medicaid·Identified Oct 15, 2025
Failed to analyze policy change
Medium impact
Idaho 2026 Individual & Family Rate Changes
PacificSource Health Plans·Effective Jan 1, 2026
Idaho health plan rates for individual and family coverage are increasing in 2026. The policy references a justification document explaining the rate increase reasons, but specific rate percentages, affected plan names, and implementation details are not provided in this announcement. Billing teams should review the full justification PDF for complete information.
High impact
November 2025 Community Solutions (Medicaid) formulary and coverage policies notification
PacificSource Health Plans·Effective Nov 15, 2025
PacificSource Community Solutions (Medicaid) has removed 7 medications from its formulary effective November 15, 2025: Brillinta 60mg tablet, Qsymia, Tasigna, Complera, Jynarque, Promacta tablets, Ixchiq, and Sandostatin LAR. Additionally, new medications released in the past year have been added to the formulary. Billing teams must identify patients on removed medications and coordinate with providers on alternative coverage options before the effective date.
Medium impact
Blue Cross and Blue Shield of Alabama Complies with New Pharmacy Law
Blue Cross Blue Shield of Alabama·Effective Oct 1, 2025
Effective October 1, 2025, Blue Cross and Blue Shield of Alabama is complying with the Alabama Community Pharmacy Relief Act, which changes how Pharmacy Benefit Managers reimburse community pharmacies. Reimbursement will now be based on the Alabama Medicaid rate (drug cost plus dispensing fee). Patient copays remain unchanged, and out-of-pocket costs will not exceed the designated copay amount. This affects prescription processing and pharmacy claims for non-Medicare commercial plans in Alabama.
Medium impact
Pharmacy Policy Updates
MVP Health Care·Identified Oct 1, 2025
MVP Health Care has released Q4 2025 pharmacy policy updates. However, the provided policy content is a general announcement page without specific policy details, billing code changes, coverage modifications, or effective dates. The actual policy updates must be accessed through the MVP Provider FastFax Library or full pharmacy policy documents referenced in the source material.
Medium impact
Medica Provider News: October 2025
Medica·Identified Oct 1, 2025
Failed to analyze policy change
High impact
Medical Policy Updates
MVP Health Care·Effective Aug 1, 2025
MVP Health Care has updated 30+ medical policies effective August 1 and October 1, 2025, covering a wide range of services including cardiac devices, orthotic devices, mental health services, surgical procedures, and mobility devices. The billing team must review detailed policy guidance in the Provider FastFax Library to understand coverage criteria, prior authorization requirements, and billing implications for each affected service.
High impact
Formulary Policy Updates
MVP Health Care·Identified Oct 1, 2025
MVP Health Care has updated its 2025 Q4 formulary, removing prior authorization requirements for 15 medications across commercial, marketplace, and self-funded plans, excluding 5 new drugs from coverage, and adding 20 newly available generic medications to formularies. These changes take effect on each member's plan year start date and require billing teams to update prior authorization workflows and formulary verification processes.
Low impact
Medicare Health Outcomes Survey is Now Available
MVP Health Care·Identified Oct 1, 2025
Medicare is launching the Health Outcomes Survey (HOS), a patient-reported outcomes measure for Medicare Advantage members. This is an informational policy announcing the availability of survey data collection to inform health outcome improvement strategies. No billing code changes or prior authorization requirements are introduced.
High impact
Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide on Oct. 1, 2025
Presbyterian Health Plan·Effective Oct 1, 2025
Presbyterian Health Plan is updating its Medical Policy Manual and Prior Authorization Guide effective October 1, 2025, adding and/or modifying prior authorization requirements for 12 procedures including bariatric surgery for pediatric patients, durable medical equipment, genetic testing, epidural injections, and hemodialysis access procedures. Billing teams must verify which procedures now require prior authorization and update workflows accordingly.
High impact
Special Alert October 2025 - Neuraxial Labor Analgesia/Anesthesia
Providence Health Plan·Effective Dec 1, 2025
Effective December 1, 2025, Providence Health Plan will cap reimbursement for CPT 01967 (neuraxial labor analgesia/anesthesia for planned vaginal delivery) at 480 units (480 minutes) for all non-Medicaid lines of business. Any units billed in excess of this cap will be denied. This is a new policy that introduces a hard limit on anesthesia time reimbursement for this procedure.
High impact
Provider Policies And Payment Policies Effective October 1 2025
MVP Health Care·Effective Oct 1, 2025
MVP Healthcare has updated its Provider and Payment Policies effective October 1, 2025. However, the provided policy document contains only introductory text and does not specify the actual policy changes, affected billing codes, or operational requirements. The billing team cannot implement changes based on this incomplete reference.
Low impact
Provider Relations Representative Profile Abby Rock
MVP Health Care·Identified Oct 1, 2025
MVP Healthcare has introduced Abby Rock as the new Provider Relations Representative for Vermont, effective October 2025. This is an informational announcement introducing a new point of contact for Vermont providers and does not contain billing, coding, coverage, or reimbursement changes.
Low impact
Mvp Living Well Programs For Your Patients
MVP Health Care·Effective Oct 1, 2025
MVP is launching free virtual and in-person wellness programs available to all patients regardless of MVP membership status. This is a provider education initiative to inform patients about available health and wellness resources, including webinars, fitness classes, and fall prevention programs. No billing, coding, or claim submission changes are required.
Medium impact
Mvp Utilizing Caqh Provider Data Portal
MVP Health Care·Effective Jul 15, 2025
MVP has partnered with CAQH to allow credentialed providers to verify and attest their demographic data through the CAQH Provider Data Portal, effective July 15, 2025. Providers are contractually required to review and attest to the accuracy of their information in the Provider Directory at least every 90 days. Registered and delegated credentialed providers should continue updating CAQH applications directly, as MVP will not access their data during the initial launch.
Low impact
Engage in Open Communication With Patients
MVP Health Care·Effective Oct 1, 2025
MVP Healthcare is encouraging providers to engage in open communication with Medicare members during wellness visits regarding sensitive health topics including urinary incontinence, fall risks, physical activity monitoring, and mental health. This is a clinical guidance update rather than a billing or coverage change. The policy also reminds providers to encourage members to complete the Medicare Health Outcomes survey (active through November 3, 2025).
Medium impact
Find Out About The Healthy Alliance Social Care Network
MVP Health Care·Effective Oct 1, 2025
Healthy Alliance is launching a Social Care Network (SCN) across the Capital Region, Central New York, and North Country to address social determinants of health for Medicaid members. Providers can become contracted partners to screen, navigate, and deliver services (food, housing, transportation, utilities) and receive reimbursement for eligible Medicaid members. The SCN aims to achieve 100% screening of attributed Medicaid population.
Medium impact
Special Alert October 2025 - Electrolysis Documentation Requirements
Providence Health Plan·Effective Dec 1, 2025
Effective December 1, 2025, Providence Health Plan requires specific documentation for all electrolysis claims related to gender affirmation on Commercial and Medicare lines of business. Documentation must include: gender dysphoria/incongruence diagnosis, WPATH SOC-8 alignment statement, clinical rationale, treatment plan with specific areas and session counts, and treatment area descriptions. This requirement applies to provider-submitted claims and direct member reimbursement requests, but excludes Providence OHP members.
High impact
Montana State Based Drug List Change Notification (Commercial)
PacificSource Health Plans·Effective Oct 1, 2025
PacificSource Montana Commercial plans are removing prior authorization requirements and formulary coverage for 60+ medications effective October 1, 2025, spanning hormone therapies, respiratory, diabetes, and specialty drugs. Billing teams must immediately update systems to stop requiring prior authorizations for these medications and verify patient coverage status, as claims submitted with unnecessary prior auth requests may be denied or delayed.
High impact
Upcoming Site of Care Program Impacts Certain Outpatient Surgeries
Highmark·Effective Jan 1, 2026
Starting January 1, 2026, Highmark will require prior authorization for certain low-risk outpatient surgeries performed in hospital outpatient departments, encouraging use of ambulatory surgery centers or office-based settings instead. Two new medical policies (Z-109 for Commercial, Z-129 for Medicare Advantage) will define covered procedures and review requirements.
High impact
2026 ICD10-CM/PCS Revisions Effective 10/1/2025
Arkansas Medicaid·Effective Oct 1, 2025
The Arkansas Department of Human Services has released the 2026 ICD-10-CM/PCS code revisions effective October 1, 2025. This annual update includes new, revised, and deleted procedure codes that must be implemented in billing systems and provider documentation to ensure accurate coding and claim processing.
Low impact
AM Best reaffirms strong financial position across Regence health plans
Regence BlueCross BlueShield of Oregon·Identified Sep 25, 2025
AM Best has upgraded Regence BlueShield of Idaho's financial strength rating from A- to A (Excellent) and reaffirmed A ratings for Regence health plans in Oregon, Utah, and Washington. This is a financial stability announcement with no direct impact on billing codes, coverage policies, prior authorization requirements, or reimbursement rates.
Low impact
60 Primary Care Physicians Now Practicing in Rural Areas of Alabama Thanks to Blue Cross and Blue Shield of Alabama’s Medical Scholarship Program
Blue Cross Blue Shield of Alabama·Identified Sep 24, 2025
This is a provider network expansion announcement from Blue Cross and Blue Shield of Alabama highlighting their medical scholarship program results. 60 primary care physicians are now practicing in rural Alabama underserved areas. This is informational news about provider recruitment and does not constitute a billing policy change affecting claims processing, coding, reimbursement, or coverage determinations.
High impact
Medical and Clinical Policy Update - Effective December 1, 2025
Sentara Health Plans·Effective Dec 1, 2025
Sentara Health Plans has updated 16 medical policies effective December 1, 2025, including archiving policies (moving to MCG guidelines or other policies), revising existing policies, and reviewing others. Key changes affect spinal surgery procedures (lumbar fusion, discectomy, laminectomy, cervical laminectomy), cardiac procedures (hemodynamic monitoring, mitral valve implantation), and orthopedic surgeries. Billing teams must identify which of these procedures your practice performs and verify updated coverage criteria and prior authorization requirements through the updated Prior Authorization List (PAL).

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Archive by year

2023 2024 2025 2026

Medicaid Peer delivered services policy update

2026 NUBC/UB04 Changes

Idaho 2026 Individual & Family Rate Changes

November 2025 Community Solutions (Medicaid) formulary and coverage policies notification

Blue Cross and Blue Shield of Alabama Complies with New Pharmacy Law

Pharmacy Policy Updates

Medica Provider News: October 2025

Medical Policy Updates

Formulary Policy Updates

Medicare Health Outcomes Survey is Now Available

Presbyterian Will Update Its Medical Policy Manual and Prior Authorization Guide on Oct. 1, 2025

Special Alert October 2025 - Neuraxial Labor Analgesia/Anesthesia

Provider Policies And Payment Policies Effective October 1 2025

Provider Relations Representative Profile Abby Rock

Mvp Living Well Programs For Your Patients

Mvp Utilizing Caqh Provider Data Portal

Engage in Open Communication With Patients

Find Out About The Healthy Alliance Social Care Network

Special Alert October 2025 - Electrolysis Documentation Requirements

Montana State Based Drug List Change Notification (Commercial)

Upcoming Site of Care Program Impacts Certain Outpatient Surgeries

2026 ICD10-CM/PCS Revisions Effective 10/1/2025

AM Best reaffirms strong financial position across Regence health plans

60 Primary Care Physicians Now Practicing in Rural Areas of Alabama Thanks to Blue Cross and Blue Shield of Alabama’s Medical Scholarship Program

Medical and Clinical Policy Update - Effective December 1, 2025