All Insurance Policy Changes (Page 16)

Continuing from page 15. 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
MA00.005at, Experimental/Investigational Services
Independence Blue Cross·Identified Jul 28, 2026
Failed to analyze policy change
Medium impact
MA08.142f, Efgartigimod alfa-fcab (Vyvgart) and efgartigimod-alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)
Independence Blue Cross·Identified Jul 28, 2026
Failed to analyze policy change
Medium impact
00.03.07as, Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Independence Blue Cross·Identified Jul 28, 2026
Failed to analyze policy change
Medium impact
08.01.07l, Pertuzumab (Perjeta®) and related biosimilar pertuzumab-dpzb (Poherdy)
Independence Blue Cross·Effective Jul 27, 2026
Policy 08.01.07l has been updated to reflect changes in medical necessity criteria and medical coding requirements for Pertuzumab (Perjeta®) and its biosimilar pertuzumab-dpzb (Poherdy®). The billing team must review updated medical necessity documentation requirements and coding guidance to ensure compliant claim submission on commercial plans effective immediately.
Medium impact
11.05.01h, Refractive Keratoplasty, Keratoprosthesis, and Corneal Collagen Cross-Linking
Independence Blue Cross·Effective Jul 27, 2026
Policy 11.05.01h regarding Refractive Keratoplasty, Keratoprosthesis, and Corneal Collagen Cross-Linking has been updated. This is a General Description, Guidelines, or Informational Update for Commercial plans. The billing team must review the updated policy guidelines to ensure accurate coverage determination and billing for these ophthalmologic procedures effective 07/27/2026.
Medium impact
12.01.01bu, Experimental/Investigational Services
Independence Blue Cross·Identified Jul 28, 2026
Failed to analyze policy change
Medium impact
08.01.84f, Efgartigimod alfa - fcab (Vyvgart)
Independence Blue Cross·Effective Oct 26, 2026
Policy 08.01.84f updates medical necessity criteria and medical coding requirements for Efgartigimod alfa - fcab (Vyvgart), a monoclonal antibody immunosuppressant. Changes take effect October 26, 2026, requiring billing teams to update authorization protocols and coding practices for this medication.
Medium impact
Reimbursement Policy Updates
BCBS Illinois·Identified Jul 28, 2026
Blue Cross Blue Shield Illinois has released a batch of reimbursement policy updates affecting six policies with staggered effective dates from June through October 2026. These updates modify payment rules and methodologies for preventive services, anesthesia, hernia repair, pneumatic compression devices, modifiers, and overlapping facility services. Billing teams must review each affected policy on the RP page and implement corresponding changes to coding and billing workflows.
Medium impact
Prior Authorization Changes for Some Commercial and Government Program Members
BCBS Illinois·Effective Oct 1, 2026
Blue Cross Blue Shield of Illinois is changing prior authorization requirements for commercial non-HMO members and Medicare Advantage/Community Health Plan members effective October 1, 2026 (commercial) and August 1, 2026 (Medicare Advantage). Musculoskeletal and select outpatient service codes will be removed from CarelonMBM and BCBSIL review for commercial members, while miscellaneous codes are being shifted between review vendors for Medicare Advantage members. Billing teams must verify eligibility and current prior authorization requirements through Availity Essentials before service delivery.
Medium impact
[Ohio] Precertification/prior authorization list change notification
Anthem BCBS·Effective Dec 1, 2026
Anthem Blue Cross and Blue Shield (Ohio) is adding 12 new services to its prior authorization/precertification requirements, effective December 1, 2026. These include 5 gene therapy procedures and 7 hematopoietic stem cell transplantation procedures for various conditions. Billing teams must obtain prior authorization before providing these services or claims will be denied.
Low impact
[Ohio] You are invited: immunization measures webinar
Anthem BCBS·Identified Jul 28, 2026
Anthem is hosting a free educational webinar on September 2, 2026, regarding HEDIS immunization measures and strategies for improving vaccination rates. This is an informational invitation for providers to attend a quality improvement training session with continuing education credits, not a policy change affecting billing or coverage.
Low impact
[Ohio] CARE+ mini-grant initiative now open for eligible LTSS providers
Anthem BCBS·Effective Aug 17, 2026
Anthem Blue Cross and Blue Shield (MyCare Ohio) has opened applications for the CARE+ mini-grant initiative, a one-time funding opportunity providing up to $5,000 per eligible long-term services and supports (LTSS) provider to support workforce development. This is a grant program, not a billing or coverage policy change, and does not affect claims processing, billing codes, or reimbursement rates for medical services.
Medium impact
[Ohio] Continued collaboration on DRG clinical and coding validation
Anthem BCBS·Effective Jul 23, 2026
Anthem Blue Cross and Blue Shield in Ohio is continuing its DRG clinical and coding validation audit program through its Complex and Clinical Audit (CCA) team and designated external vendors (EXL and Ceris). Practices should expect ongoing medical record requests and audit correspondence from Anthem and/or vendor partners. The audit review processes remain consistent, with efforts to minimize duplicate medical record requests.
Medium impact
[Virginia] VA precertification/prior authorization list change notification
Anthem BCBS·Effective Dec 1, 2026
Effective December 1, 2026, Anthem Blue Cross and Blue Shield in Virginia is adding three services to its precertification/prior authorization requirement list: noninvasive imaging for skin lesion evaluation (CPT 1020T), and two percutaneous spinal surgery procedures (CPT 62330 and 62331). Providers must obtain prior authorization before rendering these services or risk claim denial.
Low impact
[Virginia] You are invited: immunization measures webinar
Anthem BCBS·Identified Jul 28, 2026
Anthem Blue Cross and Blue Shield is hosting an educational webinar on September 2, 2026, focused on HEDIS immunization measures and strategies to improve vaccination performance. This is a provider education and training event, not a billing policy change. No changes to coverage, coding, prior authorization, or reimbursement are announced.
High impact
[Virginia] Billing reminders for manually priced durable medical equipment
Anthem BCBS·Effective Jul 26, 2026
HealthKeepers, Inc. (Anthem Medicaid in Virginia) has issued mandatory billing requirements for manually priced durable medical equipment (DME). Providers must now submit itemized invoices (not purchase orders) attached at claim submission with descriptions matching the claim, and clearly document the count of individual items per billed unit (e.g., '1 box = 100 swabs'). Claims that do not meet these requirements will be delayed or deemed ineligible for reimbursement.
Medium impact
[Virginia] Continued collaboration on DRG clinical and coding validation
Anthem BCBS·Effective Jul 23, 2026
Anthem Blue Cross and Blue Shield will continue conducting DRG clinical and coding validation audits in Virginia through its Complex and Clinical Audit (CCA) team and designated external vendors (EXL and Ceris). Healthcare providers should expect ongoing medical record requests and audit correspondence from Anthem and/or its vendor partners, with efforts to minimize duplicate requests.
Low impact
[Georgia] You are invited: immunization measures webinar
Anthem BCBS·Identified Jul 28, 2026
Anthem Blue Cross and Blue Shield is hosting an educational webinar on September 2, 2026, focused on HEDIS immunization measures and strategies to improve vaccination performance. This is an invitation to a provider training event, not a policy change affecting billing, coding, or coverage.
Medium impact
[Georgia] Continued collaboration on DRG clinical and coding validation
Anthem BCBS·Effective Jul 23, 2026
Anthem Blue Cross Blue Shield (Georgia) is continuing its DRG clinical and coding validation audit program through its Complex and Clinical Audit (CCA) team and designated external vendors (EXL and Ceris). Healthcare providers should expect ongoing medical record requests and audit correspondence from Anthem and/or its vendor partners. The audit processes and medical record request procedures remain consistent with prior practices.
High impact
Diagnosis Codes Added for Procedure Codes J3357 and J3358 Effective August 1, 2026
Texas Medicaid·Effective Aug 1, 2026
Effective August 1, 2026, Texas Medicaid will require specific diagnosis codes to be submitted with Stelara claims (HCPCS codes J3357 and J3358). Claims must include at least one diagnosis code from the approved lists for Psoriasis Arthritis, Plaque Psoriasis, Crohn's Disease, or Ulcerative Colitis to receive reimbursement. Billing teams must update claim submission protocols and provider documentation requirements immediately.
Medium impact
Update Regarding Weekend Offline Period and Access to New Critical Incident Management System
Texas Medicaid·Effective Jul 24, 2026
Texas Health and Human Services will transition the Critical Incident Management System (CIMS) to a new platform with a scheduled weekend offline period from close of business Friday, July 24, 2026 (5 p.m.) through Monday, July 27, 2026 (8 a.m.). Medicaid providers serving DBMD, CLASS, HCS, LIDDAs, and TxHmL programs will have no system access during this window. Billing teams must plan accordingly to avoid processing delays for affected Medicaid claims during this period.
High impact
July 2026 NDC-to-HCPCS Crosswalk Now Available for CAD Processing
Texas Medicaid·Effective Jul 23, 2026
Texas HHSC has released an updated July 2026 NDC-to-HCPCS Crosswalk for clinician-administered drugs (CAD). This quarterly update provides the current mapping between National Drug Codes and Medicaid-reimbursable HCPCS codes. Billing teams must access the updated crosswalk to ensure accurate claim submission with correct HCPCS coding.
Low impact
HHSC Notifies Providers of the SFY 2025 Financial Compliance Report Information
Texas Medicaid·Effective Jul 20, 2026
HHSC has published Information Letter 2026-20 requiring Long-term Services and Supports (LTSS) providers to submit State Fiscal Year 2025 Financial Compliance Reports (FCR). While submission is voluntary, providers offering Medicaid and non-Medicaid LTSS programs should be aware of the reporting requirements and September 18, 2026 deadline.
Low impact
HHSC LTCR Publishes Provider Letter 2026-13
Texas Medicaid·Effective Sep 1, 2025
HHSC LTCR has published Provider Letter 2026-13 requiring all licensed Intermediate Care Facilities for Individuals with Intellectual and Developmental Disabilities (ICF/IID) and Supported Semi-Independent Living Centers (SSLC) to implement a workplace violence prevention program per SB 463. This is an operational/compliance requirement, not a direct billing change, but affects facilities that bill for services at these provider types.
Low impact
Texas Medicaid & Healthcare Partnership IAMOnline Educational Video Now Available
Texas Medicaid·Identified Jul 28, 2026
Texas Medicaid & Healthcare Partnership (TMHP) has released a new educational video titled 'IAMOnline' to help providers access TMHP applications and systems. This is a training resource now available on the TMHP YouTube channel and Learning Management System, with supporting documentation on the TMHP Account Management webpage.

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

MA00.005at, Experimental/Investigational Services

MA08.142f, Efgartigimod alfa-fcab (Vyvgart) and efgartigimod-alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)

00.03.07as, Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products

08.01.07l, Pertuzumab (Perjeta®) and related biosimilar pertuzumab-dpzb​ (Poherdy​)

11.05.01h, Refractive Keratoplasty, Keratoprosthesis, and Corneal Collagen Cross-Linking

12.01.01bu, Experimental/Investigational Services

08.01.84f, Efgartigimod alfa - fcab (Vyvgart)

Reimbursement Policy Updates

Prior Authorization Changes for Some Commercial and Government Program Members

[Ohio] Precertification/prior authorization list change notification

[Ohio] You are invited: immunization measures webinar

[Ohio] CARE+ mini-grant initiative now open for eligible LTSS providers

[Ohio] Continued collaboration on DRG clinical and coding validation

[Virginia] VA precertification/prior authorization list change notification

[Virginia] You are invited: immunization measures webinar

[Virginia] Billing reminders for manually priced durable medical equipment

[Virginia] Continued collaboration on DRG clinical and coding validation

[Georgia] You are invited: immunization measures webinar

[Georgia] Continued collaboration on DRG clinical and coding validation

Diagnosis Codes Added for Procedure Codes J3357 and J3358 Effective August 1, 2026

Update Regarding Weekend Offline Period and Access to New Critical Incident Management System

July 2026 NDC-to-HCPCS Crosswalk Now Available for CAD Processing

HHSC Notifies Providers of the SFY 2025 Financial Compliance Report Information

HHSC LTCR Publishes Provider Letter 2026-13

Texas Medicaid & Healthcare Partnership IAMOnline Educational Video Now Available

08.01.07l, Pertuzumab (Perjeta®) and related biosimilar pertuzumab-dpzb (Poherdy)