All Insurance Policy Changes (Page 152)

Continuing from page 151. 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
[Ohio] Clinical Criteria updates
Anthem BCBS·Effective Sep 26, 2026
Anthem Blue Cross and Blue Shield Ohio Medicaid revised 16 clinical criteria policies effective September 26, 2026, covering specialty medications and biologics across multiple therapeutic categories including rare disease treatments, oncology agents, immunology drugs, and ophthalmology therapies. The revisions update medical necessity requirements for drugs administered under the medical benefit (not pharmacy benefit), requiring immediate review to identify any changes to prior authorization or documentation requirements.
High impact
[Ohio] Specialty pharmacy updates — July 2026
Anthem BCBS·Effective Oct 1, 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield (Ohio) is implementing new prior authorization requirements for four specialty pharmacy drugs, quantity limits for two drugs, and updated clinical criteria that may result in previously covered services being denied. Billing teams must begin requesting prior authorization for Fesilty, Loargys, Vykoura, and Vykoura (with oncology managed separately by Carelon), and include NDC codes on claims to expedite processing of NOC-billed drugs.
High impact
[Ohio] Home health claims for Anthem MyCare Ohio require bill type 329
Anthem BCBS·Effective Jun 23, 2026
Anthem MyCare Ohio now requires home health providers billing skilled state plan-covered services with HIPPS codes and REV code 022 to submit claims using UB-04 bill type 329 if they do not have an established per diem reimbursement rate. Claims submitted with incorrect bill types may experience processing delays or require resubmission.
Medium impact
[Ohio] Expansion of Specialty Pharmacy precertification list
Anthem BCBS·Effective Oct 1, 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield (Ohio) is expanding its specialty pharmacy precertification requirements to include two Medicare Part B drugs: Filkri (filgrastim-laha) and Ponlimsi (denosumab-adet). Both drugs will now require prior authorization and step therapy review (except for members already actively receiving these medications). Billing teams must implement precertification workflows for these HCPCS codes to avoid claim denials.
Low impact
[Ohio] Continue verifying benefits as Blue member ID cards phase out the suitcase logo
Anthem BCBS·Identified Jun 25, 2026
Anthem Blue Cross and Blue Shield is phasing out the suitcase logo on Blue member ID cards across multiple Blue Plans, replacing it with product identifiers (PPO, HMO). This change is being rolled out in phases with no completion deadline. Billing teams must continue using normal benefit verification processes and NOT use the presence or absence of the suitcase logo to determine member benefits, eligibility, or BlueCard network access.
High impact
[Ohio] Service line limits update for Medicare Advantage claims
Anthem BCBS·Identified Jun 25, 2026
Anthem Blue Cross and Blue Shield Medicare Advantage plans in Ohio will now reject claims exceeding 449 service lines (excluding the total charge line) as a single claim submission. Billing teams must implement immediate changes to combine service lines, split claims by date of service, or submit inpatient claims as interim bills to comply with this CMS alignment requirement.
High impact
[Ohio] Service line limits update for Medicare Advantage claims
Anthem BCBS·Effective Jun 24, 2026
Anthem Blue Cross and Blue Shield Medicare Advantage plans in Ohio are implementing a 449 service line limit per claim (excluding total charge line) to align with CMS encounter requirements. Claims exceeding this threshold will be rejected. Billing teams must restructure claims by combining service lines, splitting by date of service, or submitting inpatient claims as interim bills.
High impact
[Virginia] Clinical Criteria updates
Anthem BCBS·Effective Jul 23, 2026
Anthem has revised clinical criteria for 25 specialty pharmaceutical drugs and biologics effective July 23, 2026, plus introduced 2 new criteria. These are medical drug benefit policies (not pharmacy) that may affect prior authorization and medical necessity requirements for high-cost injectable and infused medications. The practice must review each specific criterion to identify changes to requirements and update authorization workflows accordingly.
High impact
[Virginia] Clinical Criteria updates
Anthem BCBS·Effective Aug 1, 2026
HealthKeepers, Inc. (Anthem Medicaid) has revised 44 clinical criteria policies and added 3 new ones effective August 1, 2026, covering medical drug benefit requirements for specialty biologics, monoclonal antibodies, cancer therapeutics, and rare disease treatments. The billing team must review updated medical necessity requirements for each affected drug to ensure claims align with new clinical criteria and avoid denials.
Medium impact
[Virginia] Carelon Medical Benefits Management updates
Anthem BCBS·Effective Aug 1, 2026
Carelon Medical Benefits Management is updating clinical appropriateness guidelines for HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid) effective August 1, 2026. Six guideline categories are being updated: Genetic Testing, Chromosomal Microarray Analysis, Genetic Liquid Biopsy in Cancer Management, Pharmacogenetic Testing, Whole Exome/Genome Sequencing, and Musculoskeletal Interventional Pain Management. Current prior authorization requirements remain unchanged; any new prior auth requirements will be communicated separately before implementation.
High impact
[Virginia] Specialty pharmacy updates — July 2026
Anthem BCBS·Effective Oct 1, 2026
Anthem Blue Cross and Blue Shield (Virginia) is implementing new prior authorization requirements, quantity limits, and updated clinical criteria for specialty pharmacy drugs effective October 1, 2026. Four drugs now require prior authorization (Fesilty, Loargys, Vykoura, and Leucovorin calcium), two drugs are subject to quantity limits (Loargys and Yuviwel), and eight clinical criteria documents have been updated that may result in previously covered services being denied as not medically necessary. Billing teams must begin requesting prior authorizations for affected specialty pharmacy claims and ensure NDC codes are included on claims using NOC billing codes.
Medium impact
[Virginia] Expansion of Specialty Pharmacy precertification list
Anthem BCBS·Effective Oct 1, 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Virginia are adding two specialty Medicare Part B drugs (Filkri and Ponlimsi) to their precertification review process. These medications will also be subject to step therapy requirements in addition to medical necessity reviews, except for members already receiving these drugs.
Low impact
[Virginia] Continue verifying benefits as Blue member ID cards phase out the suitcase logo
Anthem BCBS·Identified Jun 25, 2026
Anthem Blue Cross and Blue Shield is phasing out the suitcase logo on Blue member ID cards across multiple Blue Plans, replacing it with product identifiers (PPO/HMO). This change is being rolled out gradually with no completion deadline. Billing teams must continue verifying benefits using normal processes and must NOT use the presence or absence of the suitcase logo to determine member benefits, eligibility, or BlueCard network access.
High impact
[Virginia] Service line limits update for Medicare Advantage claims
Anthem BCBS·Effective Jun 24, 2026
Anthem Blue Cross and Blue Shield Medicare Advantage plans in Virginia are implementing a 449 service line limit per encounter (excluding total charge line) to align with CMS requirements. Claims exceeding this threshold will not be accepted as single claims. Billing teams must restructure high-volume claims by combining service lines, splitting by date of service, or submitting interim bills.
High impact
[Georgia] Clinical Criteria updates
Anthem BCBS·Effective Jul 23, 2026
Anthem Blue Cross Blue Shield (Georgia) has revised 25 clinical criteria policies and added 2 new ones effective July 23, 2026, covering specialty drugs and biologics used in Medicare Advantage medical drug benefits. These revised criteria may affect medical necessity requirements, prior authorization rules, and billing documentation for affected medications. Billing teams must review updated clinical criteria to ensure claims align with new medical necessity standards.
High impact
[Georgia] Specialty pharmacy updates — July 2026
Anthem BCBS·Effective Oct 1, 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield (Georgia) is implementing new prior authorization requirements for four specialty pharmacy drugs (Fesilty, Loargys, Vykoura, and Yuviwel), adding quantity limits to two drugs (Loargys and Yuviwel), and updating clinical criteria for eight drug classes that may result in previously covered services being denied as not medically necessary. Providers must begin requesting prior authorization for affected specialty medications on or after the effective date, and including NDC codes on claims will expedite processing.
Medium impact
[Georgia] Expansion of Specialty Pharmacy precertification list
Anthem BCBS·Effective Oct 1, 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage in Georgia is adding two specialty Medicare Part B drugs (Filkri and Ponlimsi) to its precertification review process. Both drugs will also require step therapy review upon precertification initiation, meaning patients must meet clinical criteria before coverage is approved. Claims submitted without prior authorization will be denied.
Low impact
[Georgia] Continue verifying benefits as Blue member ID cards phase out the suitcase logo
Anthem BCBS·Identified Jun 25, 2026
Anthem Blue Cross and Blue Shield member ID cards are phasing out the suitcase logo and replacing it with product identifiers (PPO/HMO). This change is being implemented gradually with no completion deadline. Billing teams must continue normal benefits verification processes regardless of logo presence or absence, as the logo change does not affect member benefits, eligibility, or BlueCard network access.
High impact
[Georgia] Service line limits update for Medicare Advantage claims
Anthem BCBS·Effective Jun 24, 2026
Anthem Blue Cross and Blue Shield Medicare Advantage plans now enforce a 449 service line limit per encounter (excluding total charge line). Claims exceeding this threshold will be rejected. Billing teams must restructure claims by combining service lines, splitting by date of service, or submitting interim bills for inpatient encounters.
Medium impact
270/271 eligibility and benefits transactions: Phase 2 enhancement launched
Cigna·Effective Jun 19, 2026
Cigna Healthcare has launched Phase 2 of their 270/271 eligibility and benefits enhancement, effective June 19, 2026. Providers can now receive NPI-specific tiered benefit information in 271 responses, allowing them to see only the benefit details applicable to their specific network tier. This reduces back-and-forth verification calls and supports CAQH CORE compliance. No immediate action is required unless your EDI vendor instructs otherwise.
Medium impact
Guidance for submitting behavioral health appeals
Cigna·Effective Jun 22, 2026
Evernorth Behavioral Health has updated its appeals process, requiring providers to submit behavioral health appeals directly to Evernorth rather than Cigna Healthcare. Appeals must include a completed Behavioral Appeals Cover Sheet Form with detailed descriptions and supporting documentation, and should be mailed to the Central Appeals Unit in Chattanooga, TN. This change aims to prevent delays and ensure more timely, efficient handling of appeal requests.
Medium impact
Clearity: Cigna Healthcare copay-only medical plan launches July 1
Cigna·Effective Jul 1, 2026
Cigna Healthcare is launching a new copay-only medical plan called Clearity effective July 1, 2026, administered by Allegiance. The plan simplifies coverage by eliminating deductibles and coinsurance, replacing them with fixed copays for office visits, laboratory services, imaging, and physical therapy. Providers in the Cigna Healthcare Open Access Plus (OAP) network will automatically be in-network for Clearity patients.
Medium impact
Prioritizing early mental health and substance use screening in 2026-2027
Cigna·Effective Jan 1, 2027
Cigna is updating medical record review indicators effective 2027 to require documentation of early mental health and substance use screening. New standards align with AAP and USPSTF guidelines: tobacco, alcohol, and depression screening for youth age 11+, adults, and pregnant/postpartum women; anxiety screening for youth age 8+, adults, and pregnant/postpartum women. Providers should begin implementing these screenings during wellness visits prior to the 2026-2027 school year to ensure compliant documentation.
Medium impact
Managing neurological conditions: How Accredo Specialty Pharmacy helps patients stay on track
Cigna·Identified Jun 25, 2026
Failed to analyze policy change
Low impact
How chronic conditions and mental health influence each other: What providers should know
Cigna·Identified Jun 25, 2026
This is an informational policy from Cigna Healthcare highlighting the clinical relationship between chronic conditions (cancer, MSK disorders, cardiometabolic diseases) and mental health. It emphasizes provider awareness of comorbid behavioral health conditions and directs providers to existing resources including the Preventive Care Services (A004) administrative policy for screening integration and Cigna's behavioral health network. No new billing requirements or code changes are introduced.

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Archive by year

2023 2024 2025 2026

[Ohio] Clinical Criteria updates

[Ohio] Specialty pharmacy updates — July 2026

[Ohio] Home health claims for Anthem MyCare Ohio require bill type 329

[Ohio] Expansion of Specialty Pharmacy precertification list

[Ohio] Continue verifying benefits as Blue member ID cards phase out the suitcase logo

[Ohio] Service line limits update for Medicare Advantage claims

[Ohio] Service line limits update for Medicare Advantage claims

[Virginia] Clinical Criteria updates

[Virginia] Clinical Criteria updates

[Virginia] Carelon Medical Benefits Management updates

[Virginia] Specialty pharmacy updates — July 2026

[Virginia] Expansion of Specialty Pharmacy precertification list

[Virginia] Continue verifying benefits as Blue member ID cards phase out the suitcase logo

[Virginia] Service line limits update for Medicare Advantage claims

[Georgia] Clinical Criteria updates

[Georgia] Specialty pharmacy updates — July 2026

[Georgia] Expansion of Specialty Pharmacy precertification list

[Georgia] Continue verifying benefits as Blue member ID cards phase out the suitcase logo

[Georgia] Service line limits update for Medicare Advantage claims

270/271 eligibility and benefits transactions: Phase 2 enhancement launched

Guidance for submitting behavioral health appeals

Clearity: Cigna Healthcare copay-only medical plan launches July 1

Prioritizing early mental health and substance use screening in 2026-2027

Managing neurological conditions: How Accredo Specialty Pharmacy helps patients stay on track

How chronic conditions and mental health influence each other: What providers should know