All Insurance Policy Changes (Page 19)

Continuing from page 18. 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
[Ohio] Office hours: new ordering, rendering, and prescribing (ORP) provider requirements
Anthem BCBS·Effective Jan 1, 2027
Ohio Medicaid is implementing new ordering, rendering, and prescribing (ORP) provider requirements effective January 1, 2027. Beginning that date, all claims for designated services (DME, laboratory, imaging, therapy, home health, hospice, dental, and transportation) must include the NPI of an actively enrolled ORP provider, and managed care entities will reject any pending or new claims with ORP NPI errors. This standardizes ORP processes across Ohio Medicaid managed care and fee-for-service programs.
Medium impact
[Ohio] Faster access to medications starts with informed prescribing
Anthem BCBS·Identified Sep 2, 2026
Anthem Blue Cross and Blue Shield (Ohio) is promoting the use of Real-Time Prescription Benefit (RTPB) and electronic Prior Authorization (ePA) tools to accelerate medication access and reduce authorization delays for Medicare Advantage members. This is an informational bulletin encouraging practices to leverage existing EHR integrations to view cost/coverage details before prescribing and submit prior authorizations electronically rather than via phone/fax.
Medium impact
[Ohio] Service initiation referrals are coming to the Referral Dashboard in Care Central
Anthem BCBS·Effective Sep 1, 2026
Beginning September 1, 2026, MyCare Ohio waiver service initiation referrals will be available through the Referral Dashboard in Care Central (Availity Essentials application). HCBS waiver providers must use this centralized platform to view, manage, and respond to referrals for members seeking to start waiver services or select a new provider. Home modification referrals remain managed separately and are not included in this dashboard.
High impact
[Ohio] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·Effective Dec 1, 2026
Effective December 1, 2026, Anthem Ohio Medicaid is implementing a new combined reimbursement policy (G-20001) that prohibits reimbursement for professional and outpatient facility claims billed with modifier 90 (pass-through laboratory billing). Providers performing tests must bill directly and will be reimbursed at 100% of the applicable fee schedule. The existing modifier 91 policy remains unchanged and continues to allow reimbursement for repeat clinical diagnostic laboratory tests at 100%.
High impact
[Ohio] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Anthem BCBS·Effective Dec 1, 2026
Effective December 1, 2026, Anthem will no longer reimburse outpatient medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 facility claims. These services are now eligible for reimbursement ONLY when submitted by the rendering provider on CMS-1500 (professional claim form). Billing teams must route these services to the correct claim form type to avoid denials.
High impact
[Ohio] Specialty pharmacy updates
Anthem BCBS·Effective Dec 1, 2026
Anthem Blue Cross and Blue Shield (Ohio) is implementing new prior authorization requirements and quantity limits for five specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for eleven additional specialty medications. Billing teams must begin requesting prior authorization for these drugs on or after the effective date, and include NDC codes on claims to expedite processing.
High impact
[Ohio] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·Effective Dec 1, 2026
Effective December 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage in Ohio is implementing a new reimbursement policy that prohibits pass-through laboratory billing using modifier 90—the performing provider must bill directly for reimbursement at 100% of the applicable fee schedule. Modifier 91 guidance remains unchanged and eligible for reimbursement on repeat clinical diagnostic laboratory tests. The existing modifier 91 policy (G-06020) will be retired and consolidated into the new combined policy (G-20001).
Medium impact
[Virginia] Prior authorization required for MED.00164
Anthem BCBS·Effective Dec 1, 2026
Effective December 1, 2026, Anthem Blue Cross and Blue Shield in Virginia now requires prior authorization for MED.00164 (Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome). Billing teams must obtain precertification before providing this service to ensure accurate reimbursement and avoid claim denials.
High impact
[Virginia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·Effective Dec 1, 2026
HealthKeepers, Inc. (Anthem) is implementing a new combined reimbursement policy (G-20001) effective December 1, 2026, that prohibits reimbursement for professional and outpatient facility claims billed with modifier 90 (pass-through laboratory billing). Providers must bill laboratory services directly to receive reimbursement at 100% of the applicable fee schedule. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and eligible for reimbursement. The previous modifier 91 policy (G-06020) will be retired.
High impact
[Virginia] Specialty pharmacy updates
Anthem BCBS·Effective Dec 1, 2026
Anthem Blue Cross and Blue Shield (Virginia) is implementing new prior authorization requirements for 5 specialty pharmacy drugs effective December 1, 2026, adding quantity limits for 3 of those drugs, and revising clinical criteria for 11 existing specialty medications. Patients currently receiving these medications without prior authorization will require prior auth requests going forward. Inclusion of NDC codes on claims will expedite processing for drugs billed with NOC codes.
High impact
[Virginia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·Effective Dec 1, 2026
Anthem Medicare Advantage is implementing a new combined reimbursement policy (G-20001) effective December 1, 2026, that prohibits pass-through laboratory billing with modifier 90 on professional and outpatient facility claims—these claims will no longer be reimbursed. Providers performing lab tests must bill directly. Modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and eligible for reimbursement. The previous modifier 91 policy (G-06020) will be retired.
Low impact
[Virginia] Help patients get the most from vaginal estrogen therapy
Anthem BCBS·Identified Sep 2, 2026
Anthem Blue Cross and Blue Shield (Virginia) has issued an educational bulletin on proper application techniques for vaginal estrogen therapy to improve treatment outcomes for recurrent UTIs in peri- and postmenopausal women. This is a provider education and counseling guidance update with no billing code changes, prior authorization modifications, or coverage alterations. The practice should incorporate these application instructions into patient counseling materials.
Low impact
[Virginia] Improve respiratory outcomes through proactive care
Anthem BCBS·Identified Sep 2, 2026
Anthem Blue Cross and Blue Shield (Virginia Medicare Advantage) is issuing a provider bulletin promoting proactive respiratory disease management for asthma and COPD patients. This is a care coordination and quality improvement initiative focused on identifying medication adherence gaps, controller therapy deficiencies, inhaler technique issues, and preventive care opportunities to reduce emergency department visits and hospitalizations. No billing code changes, prior authorization requirements, or coverage modifications are announced.
Low impact
[Virginia] Skai Blue Cross Blue Shield, a new third-party administrator of Arkansas Blue Cross Blue Shield
Anthem BCBS·Effective Jan 1, 2026
Arkansas Blue Cross Blue Shield has launched Skai Blue Cross Blue Shield, a new third-party administrator brand for national account groups (ABB, Arvest, J.B. Hunt, Simmons Foods, Paychex, Walmart, and Uniti) effective January 1, 2026. Members with Skai-branded ID cards should be treated identically to standard Blue Cross Blue Shield members with no changes to billing, eligibility verification, or cost-sharing procedures.
Medium impact
[Virginia] Manage behavioral health Peer-to-Peer conversations online
Anthem BCBS·Effective Sep 1, 2026
Anthem Blue Cross and Blue Shield (Virginia) has launched a new online peer-to-peer (P2P) conversation scheduling feature within Availity Essentials, effective September 1, 2026. Providers can now schedule and cancel P2P appointments electronically 24/7 instead of submitting requests by phone or email, reducing administrative burden and improving scheduling efficiency.
High impact
[Virginia] Review Excludes1 Notes to help keep claims on track
Anthem BCBS·Effective Oct 1, 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield (Virginia) will implement enhanced Excludes1 claim editing to enforce ICD-10-CM coding standards. Billing teams must review Excludes1 Notes before submitting claims to ensure diagnosis code combinations comply with coding guidelines. Claims with unsupported diagnosis code combinations will be subject to edit denial, requiring correction or dispute submission.
Low impact
[Virginia] Introducing the 2026 MOVE: DSP CARE Awards
Anthem BCBS·Identified Sep 2, 2026
Anthem HealthKeeks Plus (Medicaid) in Virginia has launched the 2026 MOVE: DSP CARE Awards, a recognition program for direct support professionals. This is an informational/recognition initiative with no billing, coding, or claims processing impact. Contracted provider organizations may nominate eligible DSPs for awards; this does not affect medical billing workflows, reimbursement, or claim submission.
Low impact
[Virginia] Faster access to medications starts with informed prescribing
Anthem BCBS·Identified Sep 2, 2026
Anthem Blue Cross and Blue Shield is promoting the use of Real-Time Prescription Benefit (RTPB) and electronic Prior Authorization (ePA) capabilities to streamline medication access for Medicare Advantage members in Virginia. This is an informational bulletin encouraging practices to leverage existing tools within their EHR systems to reduce prior authorization delays and improve prescription affordability, with no new mandatory requirements or billing code changes.
Medium impact
[Virginia] Medicaid 2027 work requirements: What care providers need to know
Anthem BCBS·Effective Jan 1, 2027
Starting January 1, 2027, Virginia Medicaid (Anthem HealthKeepers Plus) will implement federal work requirements for certain non-disabled adults ages 19-64 in the Medicaid Expansion population. Members must report 80 hours per month of work, school, community service, or combination thereof to maintain eligibility. Many exemptions apply (pregnant women, caregivers, veterans, etc.). Billing teams should prepare for potential eligibility changes and member disenrollments among affected populations.
High impact
[Georgia] Specialty pharmacy updates
Anthem BCBS·Effective Dec 1, 2026
Anthem Blue Cross Blue Shield Georgia is implementing new prior authorization and quantity limit requirements for 5 specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for 11 additional specialty drugs. Billing teams must request prior authorization for affected medications and include NDC codes on claims to expedite processing; previously covered patients may require new authorization for continued medication use.
Medium impact
[Georgia] Prior authorization required for MED.00164
Anthem BCBS·Effective Dec 1, 2026
Anthem Blue Cross and Blue Shield (Georgia) is adding MED.00164 (Defined Composition Cellular Immunotherapy for Select Leukemias or Myelodysplastic Syndrome) to its precertification requirements, effective December 1, 2026. Prior authorization must be obtained before providing this service to ensure accurate reimbursement and avoid claim denials.
High impact
[Georgia] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Anthem BCBS·Effective Dec 1, 2026
Effective December 1, 2026, Anthem will no longer reimburse medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 (facility claims). These services are now eligible for reimbursement ONLY when submitted on CMS-1500 (professional claim form) by the rendering provider. Billing teams must immediately audit billing workflows to prevent claim denials and ensure correct claim form submission.
High impact
[Georgia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·Effective Dec 1, 2026
Effective December 1, 2026, Anthem Medicare Advantage is implementing a new combined reimbursement policy (G-20001) that prohibits reimbursement for laboratory services billed with modifier 90 (pass-through billing). Providers must bill directly for laboratory services and will be reimbursed at 100% of the applicable fee schedule. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and is consolidated into this new policy. The prior modifier 91 policy (G-06020) is being retired.
High impact
[Georgia] Review Excludes1 Notes to help keep claims on track
Anthem BCBS·Effective Oct 1, 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield in Georgia will implement enhanced Excludes1 claim editing to enforce ICD-10-CM coding standards. Billing teams must review Excludes1 Notes before submitting claims to prevent diagnosis code combinations that violate coding guidelines. Claims rejected for Excludes1 violations require either corrected submissions with appropriate codes or disputes supported by ICD-10-CM documentation.
Low impact
[Georgia] Help patients get the most from vaginal estrogen therapy
Anthem BCBS·Identified Sep 2, 2026
This is an educational bulletin from Anthem Blue Cross Blue Shield (Georgia) providing clinical guidance on proper vaginal estrogen cream application to improve treatment outcomes for recurrent UTIs in peri- and postmenopausal women. The policy emphasizes patient counseling techniques to minimize medication waste and improve effectiveness, but does not introduce new billing requirements, coverage changes, or prior authorization mandates.

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Insurance Policy Changes Tracker: All Payer Updates (Page 19) | PolicyChanges.app

[Ohio] Office hours: new ordering, rendering, and prescribing (ORP) provider requirements

[Ohio] Faster access to medications starts with informed prescribing

[Ohio] Service initiation referrals are coming to the Referral Dashboard in Care Central

[Ohio] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

[Ohio] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility

[Ohio] Specialty pharmacy updates

[Ohio] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

[Virginia] Prior authorization required for MED.00164

[Virginia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

[Virginia] Specialty pharmacy updates

[Virginia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

[Virginia] Help patients get the most from vaginal estrogen therapy

[Virginia] Improve respiratory outcomes through proactive care

[Virginia] Skai Blue Cross Blue Shield, a new third-party administrator of Arkansas Blue Cross Blue Shield

[Virginia] Manage behavioral health Peer-to-Peer conversations online

[Virginia] Review Excludes1 Notes to help keep claims on track

[Virginia] Introducing the 2026 MOVE: DSP CARE Awards

[Virginia] Faster access to medications starts with informed prescribing

[Virginia] Medicaid 2027 work requirements: What care providers need to know

[Georgia] Specialty pharmacy updates

[Georgia] Prior authorization required for MED.00164

[Georgia] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility

[Georgia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

[Georgia] Review Excludes1 Notes to help keep claims on track

[Georgia] Help patients get the most from vaginal estrogen therapy