All Insurance Policy Changes (Page 143)

Continuing from page 142. 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
00.01.52ab, Bundled Procedure Codes
Independence Blue Cross·Identified Jun 27, 2026
Failed to analyze policy change
Low impact
EWC DETEC Application Enhancements in the Provider Portal
Medi-Cal·Effective Jun 26, 2026
The EWC DETEC application in the California Medi-Cal Provider Portal has been updated with four operational changes: Mother's Maiden Name is now required for recipient creation/recertification, referral providers can now print recipient ID cards, the sexual orientation field has been removed from the Compare Recipient screen, and Date of Birth has been removed from printed Recipient Cards. These changes aim to reduce duplicate records, improve workflow, and enhance data security.
Medium impact
Clarification to Existing Community Health Worker (CHW) Preventive Services Policy
Medi-Cal·Effective Jun 26, 2026
The California Department of Health Care Services clarified that Community Health Workers (CHWs) may now bill Medi-Cal for assisting members with maintaining or obtaining enrollment in Medi-Cal and other government assistance programs (CalWORKS, CalFRESH, etc.). This expands the scope of reimbursable CHW preventive services. All existing Medi-Cal Presumptive Eligibility policies apply to CHW services in the same manner as other covered services.
Medium impact
Important: EWC Program Support to Transition to DHCS
Medi-Cal·Effective Jul 1, 2026
Effective July 1, 2026, administration of the Every Woman Counts (EWC) program transitions from Regional Contractors to the Department of Health Care Services (DHCS). Covered services and member eligibility remain unchanged, but billing and clinical teams must update contact information and routing procedures for all EWC-related inquiries, claims, and provider support.
Low impact
Paperless Notice of Action Letters in the Provider Portal
Medi-Cal·Effective Jun 29, 2026
Beginning June 29, 2026, Provider Organization Administrators can opt into a paperless option for Notice of Action-Provider Copy letters through the Provider Portal. Organizations selecting this feature will no longer receive mailed copies and instead access letters via the Provider Portal Correspondence Center. This is an optional administrative feature with no impact on billing codes or clinical operations.
High impact
Adaptive Maintenance (new and revised codes) Addition
Blue Cross Blue Shield of Vermont·Effective Sep 1, 2026
Blue Cross VT released four new HCPCS codes (G0681, G0682, G0683, G0684) retroactive to January 1, 2026. These codes are classified as informational by Blue Cross VT and require billing team awareness for proper claims processing. Additionally, maternity care billing is transitioning to new E/M codes with modifier -TH and Z34A ICD-10 codes effective September 1, 2026, replacing legacy global obstetric codes.
High impact
[New York] Specialty pharmacy updates — July 2026
Anthem BCBS·Effective Oct 1, 2026
Anthem Blue Cross and Blue Shield is implementing new step therapy requirements for specialty pharmacy medications effective October 1, 2026. Nivolumab (Opdivo) products now require prior authorization review for continued patient use, even if patients are currently receiving these medications without prior auth. Practices must begin requesting prior authorization for these oncology medications on or after the effective date.
Medium impact
[Ohio] Clinical Criteria updates (July 2026 Newsletter)
Anthem BCBS·Identified Jun 27, 2026
This is a provider bulletin announcing multiple clinical criteria updates from Anthem Blue Cross and Blue Shield for Ohio plans (Medicare Advantage, Medicaid, and MyCare Ohio). However, the actual clinical criteria details are not included in this newsletter—providers must access linked documents for specific policy changes. Multiple effective dates range from September 8 through October 1, 2026.
Medium impact
[Ohio] Correction to Medicaid EOP appeal language
Anthem BCBS·Effective Jun 26, 2026
Anthem Blue Cross and Blue Shield Medicaid (Ohio) corrected a system error that incorrectly directed providers to submit external appeals to the Wisconsin Medicaid address for claims processed between May 15–June 10, 2026. Providers must now use the correct Ohio-specific appeal submission methods (online via Availity, fax, email, or phone) for all Ohio Medicaid claims.
Medium impact
[Ohio] Specialty pharmacy updates — July 2026
Anthem BCBS·Effective Oct 1, 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield in Ohio is implementing new step therapy requirements for specialty pharmacy medications. Patients currently receiving Opdivo (nivolumab, J9299) and Opdivo Qvantig (nivolumab hyaluronidase-nvhy, J9289) without prior authorization will now require prior authorization review for continued use. Providers must request prior authorization for these medications on or after the effective date.
High impact
[Virginia] Correction to Medicaid EOP appeal language
Anthem BCBS·Effective Jun 26, 2026
HealthKeepers, Inc. corrected a system error that incorrectly directed Virginia Medicaid providers to submit appeals to Wisconsin Medicaid addresses on EOPs issued May 15–June 10, 2026. Providers must now ensure all Medicaid claim appeals and reconsiderations are submitted to the correct state-specific process (Virginia), using HealthKeepers' three appeal methods: oral, online via Availity Essentials, or written mail to Virginia Beach.
High impact
[Virginia] Specialty pharmacy updates — July 2026
Anthem BCBS·Effective Oct 1, 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield is implementing new step therapy requirements for specialty pharmacy medications in Virginia. Nivolumab (Opdivo) products will now require prior authorization review before patients can continue receiving these medications, even if they are currently on therapy without prior authorization.
Medium impact
[Georgia] Specialty pharmacy updates — July 2026
Anthem BCBS·Effective Oct 1, 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield is implementing new step therapy requirements for specialty pharmacy medications, specifically nivolumab (Opdivo) products. Patients currently receiving these medications without prior authorization will now require prior authorization review for continued use. Two formulations are affected: nivolumab (J9299, preferred) and nivolumab hyaluronidase-nvhy (J9289, non-preferred).
Low impact
Supporting youth mental health: Expanding access and strengthening community care
Cigna·Identified Jun 27, 2026
This is a Cigna Group Foundation grant announcement for youth mental health initiatives, not a billing policy change. The $3 million in grants to 22 nonprofits across 10 states focuses on expanding access to mental health services for youth ages 5-18 and strengthening community support systems. This is informational/marketing content with no direct impact on billing workflows, coding, or reimbursement.
High impact
Mandatory RBT Credential, 90-day Grace Period, and Billing Compliance for ABA
Missouri Medicaid (MO HealthNet)·Effective Jun 26, 2026
MO HealthNet implemented a mandatory credential requirement for Registered Behavior Technicians (RBTs) with a 90-day grace period for new staff to obtain BACB certification. Billing teams must immediately track all uncredentialed behavior technicians, flag their grace period milestones (days 30, 45, 60), and stop submitting claims on day 91 if certification is not obtained. Non-compliant claims submitted beyond the 90-day window are subject to full recoupment.
High impact
Reimbursement Policies Updated in June 2026
Healthfirst·Effective Jan 1, 2024
Healthfirst has expanded NDC (National Drug Code) billing requirements effective 01/01/2024, with updates approved 06/15/2026. All outpatient drug claims must now include complete NDC information in 5-4-2 format (11 digits), unit of measure (UOM) qualifiers, and NDC quantity. 340B program providers must additionally include the UD modifier. Claims missing or containing incorrect NDC data will be denied or reprocessed.
High impact
Updates to ASD Services Provider Manual
SC Medicaid - SCDHHS·Effective Jul 1, 2026
South Carolina SCDHHS has updated the ASD Services Provider Manual effective July 1, 2026, with changes to telehealth guidance, medical necessity criteria, service descriptors, and documentation requirements. A critical new anti-kickback rule prohibits reimbursement for ABA services provided by clinics or agencies owned by entities that also conducted the member's autism evaluation and diagnosis.
Medium impact
Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)
Humana·Identified Jun 27, 2026
This is a 1-day-old Medicare Advantage policy revision regarding ambulatory cardiac monitoring devices used for home-based heart rhythm recording to diagnose and manage cardiac arrhythmias, cryptogenic stroke, palpitations, and syncope. The policy covers multiple device types including Holter monitors, patch monitors, external loop recorders, and implantable loop recorders, but the provided content is incomplete (summary only) and does not specify coverage criteria, billing codes, reimbursement rates, or prior authorization requirements needed for implementation.
Medium impact
Reimbursement Policies
EmblemHealth·Effective Jun 13, 2025
EmblemHealth and ConnectiCare are introducing a new laboratory benefit management reimbursement policy effective June 13, 2025, specifically addressing therapeutic drug monitoring of 5-Fluorouracil. Additionally, 11 other laboratory and diagnostic imaging policies have been updated with revised reimbursement guidance. Billing teams must review revision histories for each affected policy to identify specific effective dates and applicable changes.
High impact
Billing for Prenatal/Postpartum Visits
EmblemHealth·Effective Apr 15, 2025
Effective April 15, 2025, EmblemHealth now requires Category II CPT codes (0500F, 0502F, or 0503F) to be included on all claims for prenatal and postpartum services billed with global codes for New York Medicaid members. Claims submitted without the appropriate Category II code will be denied.
Medium impact
View Reminders and Quick Tips for Medicaid Authorizations
BCBS Illinois·Effective Apr 1, 2026
Blue Cross and Blue Shield of Illinois launched a new Medicaid Authorizations application within Availity Essentials in April 2026 to streamline prior authorization submissions for Illinois Medicaid members. This policy provides navigation tips, access instructions, and reminders for using the new portal to submit and manage utilization management requests.
Medium impact
MTM Health To Provide Medical Transportation for Medicaid Members
BCBS Illinois·Effective Oct 1, 2026
Effective October 1, 2026, MTM Health will replace Modivcare as the sole nonemergency medical transportation provider for Medicaid members. Eligible patients must contact MTM Health to request transportation services going forward, though recurring trips and pre-scheduled trips after Oct 1 will automatically transfer. The billing team should expect a transition in how transportation benefit claims are processed and routed.
Low impact
CME Webinar: Lifestyle Medicine in Practice: Evidence‑Based Strategies for Chronic Disease Care
UPMC Health Plan·Effective Sep 23, 2026
This is a CME educational webinar announcement on lifestyle medicine for chronic disease management, not a billing policy change. No billing codes, coverage rules, reimbursement rates, or clinical workflows are affected. This is informational content about a continuing education opportunity for providers.
Low impact
Hospital Presumptive Eligibility Portal – Addition of Aid Code “AO” for Aged Out of Foster Care Youth, effective June 26, 2026
Nevada Medicaid·Effective Jun 26, 2026
Nevada Medicaid is adding a new aid code 'AO' to the Hospital Presumptive Eligibility Portal effective June 26, 2026, to identify and enroll Aged Out of Foster Care Youth (under age 26 who aged out of state/tribal foster care and were enrolled in Medicaid). This is a portal/eligibility system update that does not affect billing codes or clinical workflows.
Medium impact
February 28, 2024 Kaiser Permanente members gain access to Boulder Community Health Boulder Valley Care Network providers also available to Kaiser Permanente …
Kaiser Permanente·Effective Feb 28, 2024
Kaiser Permanente members in Colorado now have access to Boulder Community Health Boulder Valley Care Network providers. This is a provider network expansion that may affect in-network status, referral requirements, and claim routing for affected members. Billing teams must verify patient eligibility and in-network status for these newly accessible providers.

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Insurance Policy Changes Tracker: All Payer Updates (Page 143) | PolicyChanges.app

00.01.52ab, Bundled Procedure Codes

EWC DETEC Application Enhancements in the Provider Portal

Clarification to Existing Community Health Worker (CHW) Preventive Services Policy

Important: EWC Program Support to Transition to DHCS

Paperless Notice of Action Letters in the Provider Portal

Adaptive Maintenance (new and revised codes) Addition

[New York] Specialty pharmacy updates — July 2026

[Ohio] Clinical Criteria updates (July 2026 Newsletter)

[Ohio] Correction to Medicaid EOP appeal language

[Ohio] Specialty pharmacy updates — July 2026

[Virginia] Correction to Medicaid EOP appeal language

[Virginia] Specialty pharmacy updates — July 2026

[Georgia] Specialty pharmacy updates — July 2026

Supporting youth mental health: Expanding access and strengthening community care

Mandatory RBT Credential, 90-day Grace Period, and Billing Compliance for ABA

Reimbursement Policies Updated in June 2026

Updates to ASD Services Provider Manual

Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)

Reimbursement Policies

Billing for Prenatal/Postpartum Visits

View Reminders and Quick Tips for Medicaid Authorizations

MTM Health To Provide Medical Transportation for Medicaid Members

CME Webinar: Lifestyle Medicine in Practice: Evidence‑Based Strategies for Chronic Disease Care

Hospital Presumptive Eligibility Portal – Addition of Aid Code “AO” for Aged Out of Foster Care Youth, effective June 26, 2026

February 28, 2024 Kaiser Permanente members gain access to Boulder Community Health Boulder Valley Care Network providers also available to Kaiser Permanente …