All Insurance Policy Changes (Page 2)

Continuing from page 1. 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
BT2026127: Pharmacy updates approved by Drug Utilization Review Board July 2026
Indiana Medicaid (IHCP)·Effective Oct 1, 2026
Indiana Health Coverage Programs (IHCP) has updated pharmacy prior authorization (PA) criteria, the Statewide Uniform Preferred Drug List (SUPDL), and the Preferred Brand Drug List effective October 1, 2026. Changes include removal of certain brand drugs from SUPDL, updates to step therapy requirements, quantity limit modifications, and preferred status changes for multiple drug classes including respiratory agents, cardiac medications, mental health drugs, and immunomodulators. PA system enhancements affect 9 drug categories with new automated criteria.
Medium impact
BT2026128: IHCP presents status of claim-processing payment for impacted CCBHC claims
Indiana Medicaid (IHCP)·Identified Jul 31, 2026
IHCP is reprocessing previously denied claims for Indiana Medicaid CCBHC providers stemming from a January 28, 2026 system implementation. Two specific issues are being corrected: (1) erroneous claim denials for members with third-party liability on optical coverage, and (2) incorrect denials for members in the 590 Program with EOB code 2033. Providers do not need to resubmit affected claims as IHCP will automatically reprocess them.
High impact
BT2026129: OMPP changing lookback period for claims with retroactive QMB coverage
Indiana Medicaid (IHCP)·Effective Sep 1, 2026
Indiana Medicaid (IHCP) is extending the QMB claim reprocessing lookback period from 24 months to 36 months for members with retroactive Medicare coverage. Effective September 1, 2026, providers must resubmit affected claims with dates of service on or after September 1, 2023. This change applies to both fee-for-service and managed care claims for dually eligible Medicare/Medicaid members.
High impact
2026-07-30 - FY 2027 Skilled Nursing Facility Prospective Payment System Final Rule
Medicare/CMS·Effective Oct 1, 2027
CMS issued final FY 2027 payment rules for skilled nursing facilities (SNF) and inpatient psychiatric facilities (IPF), increasing SNF PPS rates by 2.4% ($882.74M aggregate) and IPF rates by 2.3% ($60M aggregate). The policy also updates SNF and IPF Quality Reporting Programs, implements new IPF outlier payment caps (20% effective FY 2028), and includes requirements for clinical labs to report private payor data by July 31, 2026, with new DMEPOS conditions of payment for 20 additional items.
Medium impact
Prostate Artery Embolization for Benign Prostatic Hyperplasia (7.01.55)
Blue Shield of California·Effective Aug 1, 2026
Blue Shield of California has classified Prostate Artery Embolization (PAE) for benign prostatic hyperplasia as investigational, effective August 1, 2026. This means PAE procedures will not be covered as a standard treatment; claims will be denied unless the member's contract specifically provides coverage for investigational procedures or state law mandates coverage of FDA-approved services. Billing teams must implement prior authorization requirements and set up denial protocols.
High impact
Evaluation of Cerebrospinal fluid, Urine, and Plasma Tests for Alzheimer Disease (2.04.14)
Blue Shield of California·Effective Aug 1, 2026
Blue Shield of California significantly narrowed coverage for Alzheimer's biomarker testing effective August 1, 2026. CSF testing for amyloid beta and tau is now covered ONLY when using three specific FDA-approved tests as part of evaluation for initiating amyloid beta-targeting therapy (lecanemab/donanemab) in patients with mild cognitive impairment or mild dementia. Plasma testing and all other scenarios (diagnostic adjunct, continuation therapy, neural thread proteins, urine testing) are classified as investigational and not covered.
High impact
Circulating Tumor-Tissue-Modified Viral DNA Testing for Cancer Management (2.04.160)
Blue Shield of California·Effective Aug 1, 2026
Blue Shield of California has issued a new medical policy (2.04.160) effective August 1, 2026, designating Circulating Tumor-Tissue-Modified Viral (TTMV) HPV DNA testing (NavDx) as investigational for cancer management. This test cannot be covered for HPV-related head and neck squamous cell carcinoma (HNSCC), anal squamous cell carcinoma (ASCC), or to determine HPV-related cancer status due to insufficient evidence of clinical utility.
Medium impact
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome (7.01.101)
Blue Shield of California·Effective Aug 1, 2026
Blue Shield of California updated its surgical treatment policy for obstructive sleep apnea (OSA) and snoring, effective August 1, 2026. The policy establishes specific medical necessity criteria for multiple surgical procedures including palatopharyngoplasty, hypoglossal nerve stimulation, hyoid suspension, mandibular-maxillary advancement, and adenotonsillectomy, while classifying several minimally invasive techniques (laser-assisted palatoplasty, radiofrequency tissue reduction, palatal stiffening procedures) as investigational. Billing teams must ensure prior authorization processes align with these updated criteria and investigational procedure classifications.
Medium impact
Skeletal Remodeling (BSC7.21)
Blue Shield of California·Effective Aug 1, 2026
Blue Shield of California has classified rib remodeling procedures (WASP, RIBOSS, RibXcar, UUAIST) as investigational and clavicle shortening for body contouring as investigational. Scapular shaving/contouring for aesthetic or gender affirmation purposes is now considered not medically necessary. This policy becomes effective August 1, 2026, and will impact claims submission and prior authorization requirements for these procedures.
High impact
Place of Service Policy for Outpatient Procedures (BSC10.01)
Blue Shield of California·Effective Aug 1, 2026
Blue Shield of California updated its Place of Service Policy (BSC10.01) effective August 1, 2026, establishing comprehensive criteria for determining appropriate settings for outpatient procedures—outpatient hospital facilities (POS 19/22), ambulatory surgery centers (POS 24), or office settings (POS 11). The policy now includes 22 specific medical conditions that require hospital outpatient setting, accessibility barriers that justify hospital use, and detailed criteria for ASC eligibility. Billing teams must validate place of service claims against these clinical criteria and accessibility requirements.
Medium impact
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry (2.02.08)
Blue Shield of California·Effective Aug 1, 2026
Blue Shield of California updated its policy on ambulatory event monitors and mobile cardiac outpatient telemetry, effective August 1, 2026. The policy clarifies medical necessity criteria for external ambulatory event monitors, implantable monitors, and cardiac telemetry for specific cardiac conditions including infrequent arrhythmia symptoms, post-ablation atrial fibrillation monitoring, and cryptogenic stroke evaluation. Certain uses (asymptomatic monitoring, medication effectiveness tracking, and ischemia detection) remain investigational and non-covered.
High impact
All Provider Bulletin 418: Update to Certain Exceptions to Referral Requirements through the Primary Care Clinician Plan and Primary Care Accountable Care Organizations: Radiology and Imaging
MassHealth·Effective Aug 1, 2026
Effective August 1, 2026, MassHealth eliminates referral requirements for all radiology and imaging services provided to members in the Primary Care Clinician (PCC) Plan or Primary Care ACO. However, these services remain subject to ordering, referring, and prescribing (ORP) provider requirements. This change simplifies access to imaging but does not eliminate all authorization requirements.
High impact
Nursing Facility Bulletin 201: Updates to Instructions for Nursing Facility Fee-for-Service Payments: MDS 3.0 Assessments
MassHealth·Effective Jul 1, 2026
MassHealth updated nursing facility MDS 3.0 assessment payment instructions effective July 1, 2026, superseding Bulletin 197. Key changes include: (1) new guidance on retroactive eligibility and modified MDS assessments, (2) expanded MDS audit requirements to include up to 100% of admission, quarterly, and annual assessments with focus on modified assessments resulting in higher PDPM scores for claims dated 10/1/2023 or later, and (3) clarified auditing procedures for behavioral indicator add-on claims. Nursing facilities must ensure MassHealth provider ID and member ID are on all MDS submissions or resubmit modified assessments.
Medium impact
2026 May Network Connection
Presbyterian Health Plan·Identified Jul 31, 2026
Presbyterian's May 2026 Network Connection newsletter emphasizes quality measure compliance and operational requirements for contracted providers. Key highlights include: (1) Kidney Health Evaluation (KED) HEDIS measure focus requiring annual eGFR and uACR testing for diabetic patients with emphasis on closing the uACR screening gap; (2) 2025 medical record review results showing 97.8% overall compliance but critical gaps in Advance Directives documentation (27.2%) and immunization recording; (3) mandatory provider directory verification deadline of June 30, 2026 per No Surprises Act requirements; and (4) multiple provider education events and wellness resources. This is informational and compliance-focused rather than a billing code or coverage change.
High impact
2026 July Network Connection
Presbyterian Health Plan·Effective Jul 1, 2026
Presbyterian has issued updated billing guidance for CPT 90785 (interactive complexity) with stricter documentation requirements and clarification on qualifying vs. non-qualifying uses. Providers must now document specific communication challenges, clinical interaction barriers, and why standard communication approaches were insufficient. Additionally, nail pathogen panel overutilization concerns are flagged, requiring providers to document clinical necessity and avoid unnecessary repeat testing.
Medium impact
OfficeLink Updates - August 2026 notices and reminders (PDF)
Aetna·Identified Jul 30, 2026
Failed to analyze policy change
Medium impact
Drug Policy Criteria Change
Arkansas Blue Cross Blue Shield·Effective Aug 20, 2026
This pharmacy policy update, effective 08/20/2026, makes multiple drug formulary changes across 11 medications/drug classes: adds Trimbow to target drug list, restructures hydrocortisone acetate and corticosteroid criteria while removing brand references, removes discontinued products (Loprox, Mentax, Patanase, Beconase AQ, Symjepi), updates Voquezna quantity limits and approval duration, changes testosterone product coverage language from 'gender dysphoria' to 'gender-affirming care,' updates Zoryve age requirements, expands Truqap to include prostate cancer coverage, and consolidates fulvestrant product coverage. Billing and prior authorization teams must update drug formulary files and coverage criteria across all affected plan types.
High impact
Drug Policy Criteria Change
Arkansas Blue Cross Blue Shield·Identified Jul 30, 2026
Unable to analyze this policy change. The policy content appears to be corrupted or encrypted (contains garbled text: 'uwt{nijw stynknhfynts tk wjyfnq iwzl...'). While the title suggests a drug policy criteria change involving Savitrux, the actual policy details cannot be reliably extracted or interpreted. Recommend obtaining a clean copy of the policy document from the source URL before implementation.
High impact
[California] Independent FFS Physicians option — FAQ
Anthem BCBS·Effective Jul 29, 2026
Anthem Blue Cross has formalized the Independent FFS Physicians option for California providers treating Pathway HMO members. Providers in this network bill HMO members using PPO fee-for-service rates and must follow specific authorization and referral requirements. Billing teams must implement new workflows for prior authorization submission (via fax only, not Availity), referral management, and member identification verification.
Medium impact
[California] Independent FFS physicians: what PPO providers need to know
Anthem BCBS·Effective Jul 29, 2026
Anthem Blue Cross has introduced an Independent FFS care model for Pathway HMO members allowing them to receive care from PPO network providers. Billing teams must bill these claims on an FFS basis using the same PPO fee schedule, include authorization numbers when required, and ensure specialty referrals are obtained (except for behavioral health and non-referral services). Ending a PPO agreement will affect participation in the Pathway HMO network.
Medium impact
[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (August 2026 Newsletter)
Anthem BCBS·Effective Nov 1, 2026
Carelon Medical Benefits Management has updated prior authorization requirements across multiple service categories effective November 1, 2026 (December 1 for Radiation Therapy). Changes affect Genetic Testing, Musculoskeletal, Surgical, DME/POS, Cardiology, Radiology, and Radiation Therapy services across Commercial, Medicare Advantage, and Medicaid plans in New York. The policy document references updated guidelines but specific authorization requirement changes are not detailed in this newsletter announcement.
High impact
[Georgia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (August 2026 Newsletter)
Anthem BCBS·Effective Nov 1, 2026
Carelon Medical Benefits Management has updated prior authorization requirements across multiple service categories effective November 1, 2026 (December 1, 2026 for Radiation Therapy). Changes affect Genetic Testing, Surgical procedures, DME/POS, Cardiology, and Base Surgical services for both Commercial and Medicare Advantage plans in Georgia. Specific authorization thresholds and documentation requirements have been modified.
Medium impact
Specialty Medical Injectables with Reimbursement Restriction
Cigna·Effective Jul 14, 2026
Cigna Healthcare has added three new specialty medical injectables to their reimbursement restriction list, effective on staggered dates between April and July 2026. When these injectables are administered in outpatient hospital settings and covered under the medical benefit, claims must be submitted by a Cigna Healthcare–contracted specialty pharmacy. The restriction does not apply to provider offices, non-hospital ambulatory infusion suites, or home settings.
Medium impact
Immunization Fee Schedule (NIIFS) quarterly update
Cigna·Effective Aug 1, 2026
Cigna Healthcare's National Injectable and Immunization Fee Schedule (NIIFS) has been updated for the third quarter of 2026 and will become effective August 1, 2026. The billing team must obtain the updated fee schedule to ensure accurate reimbursement for injectable drugs and immunization administration services.
High impact
Cigna Healthcare medical Individual & Family Plans to be discontinued, effective January 1, 2027
Cigna·Effective Jan 1, 2027
Cigna Healthcare is discontinuing all medical Individual & Family Plans (IFPs) effective January 1, 2027. Affected patients will lose coverage on December 31, 2026, and must select new insurance for 2027. Cigna commercial group plans and dental IFPs are unaffected. Claims submitted within required timelines for services incurred during active coverage will still be processed.

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Archive by year

2023 2024 2025 2026

BT2026127: Pharmacy updates approved by Drug Utilization Review Board July 2026

BT2026128: IHCP presents status of claim-processing payment for impacted CCBHC claims

BT2026129: OMPP changing lookback period for claims with retroactive QMB coverage

2026-07-30 - FY 2027 Skilled Nursing Facility Prospective Payment System Final Rule

Prostate Artery Embolization for Benign Prostatic Hyperplasia (7.01.55)

Evaluation of Cerebrospinal fluid, Urine, and Plasma Tests for Alzheimer Disease (2.04.14)

Circulating Tumor-Tissue-Modified Viral DNA Testing for Cancer Management (2.04.160)

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome (7.01.101)

Skeletal Remodeling (BSC7.21)

Place of Service Policy for Outpatient Procedures (BSC10.01)

Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry (2.02.08)

All Provider Bulletin 418: Update to Certain Exceptions to Referral Requirements through the Primary Care Clinician Plan and Primary Care Accountable Care Organizations: Radiology and Imaging

Nursing Facility Bulletin 201: Updates to Instructions for Nursing Facility Fee-for-Service Payments: MDS 3.0 Assessments

2026 May Network Connection

2026 July Network Connection

OfficeLink Updates - August 2026 notices and reminders (PDF)

Drug Policy Criteria Change

Drug Policy Criteria Change

[California] Independent FFS Physicians option — FAQ

[California] Independent FFS physicians: what PPO providers need to know

[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (August 2026 Newsletter)

[Georgia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (August 2026 Newsletter)

Specialty Medical Injectables with Reimbursement Restriction

Immunization Fee Schedule (NIIFS) quarterly update

Cigna Healthcare medical Individual & Family Plans to be discontinued, effective January 1, 2027