All Insurance Policy Changes (Page 3)

Continuing from page 2. 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
AHCCCS Seeks Public Comment on HCBS Needs Tool (HNT) and Extraordinary Care Review (ECR) Rulemaking
Arizona Medicaid - AHCCCS·Identified Sep 15, 2026
AHCCCS is seeking public comment (through October 12, 2026) on proposed exempt rulemaking that will strengthen the Home and Community Based Services (HCBS) Needs Tool assessment process and implement an Extraordinary Care Review (ECR) process for ALTCS members under age 18. The rulemaking will establish MCO obligations, require specialized ECR clinician training, and affect service hour determinations for pediatric long-term care members in Arizona.
High impact
Patient Lifts (e.g., Hoyer, Saralift, Seat Lift, Chair Mechanisms, and Ceiling Lifts) 1.01.08
Excellus BlueCross BlueShield·Effective Jul 17, 2025
Excellus BlueCross BlueShield issued a new Patient Lifts policy (1.01.08) effective July 17, 2025, establishing comprehensive coverage criteria for patient lifts, seat lift mechanisms, and related DME. The policy explicitly excludes bathroom lifts, ceiling lifts, platform lifts, stair lifts, and powered wheelchair lifts from coverage. Billing teams must immediately update claim submission rules to deny claims for excluded device types and implement documentation requirements for all lift-related authorizations.
Medium impact
Patient Lifts - (Effective Date - 2026-11-16) 1.01.08
Excellus BlueCross BlueShield·Effective Nov 16, 2026
Excellus BlueCross BlueShield has updated its Patient Lifts policy (1.01.08) effective November 16, 2026, establishing specific medical necessity criteria for coverage of patient lifts, seat lift chair mechanisms, and DME repair/replacement. The policy explicitly excludes bathroom lifts, ceiling lifts, platform lifts, stair gliders, and powered wheelchair lifts from coverage. Billing teams must ensure claims meet all stated criteria and use only covered HCPCS codes to avoid denials.
Medium impact
MA08.098b, Tildrakizumab-asmn (Ilumya®)
Independence Blue Cross·Effective Sep 14, 2026
Policy MA08.098b updates coverage and reimbursement criteria for Tildrakizumab-asmn (Ilumya®), a biologic medication for psoriasis. The policy includes changes to medical necessity criteria, billing codes, and general coverage guidelines effective September 14, 2026. The billing team must review the full policy document to identify specific code changes and prior authorization requirements.
High impact
MA08.086e, Nusinersen (Spinraza®)
Independence Blue Cross·Effective Sep 14, 2026
Policy MA08.086e for Nusinersen (Spinraza®) has been updated effective 09/14/2026. This is a Medicare Advantage policy addressing coverage, reimbursement position, and medical necessity criteria for this specialty pharmaceutical. The billing team must immediately obtain the full policy details to understand specific coverage requirements, prior authorization mandates, and any changes to reimbursement methodology.
Medium impact
08.01.48c, Tildrakizumab-asmn (Ilumya®)
Independence Blue Cross·Effective Sep 14, 2026
Policy 08.01.48c regarding Tildrakizumab-asmn (Ilumya®) has been updated, effective September 14, 2026. The policy change encompasses coverage and/or reimbursement position, medical necessity criteria, medical coding, and general guidelines for this biologic immunosuppressant medication used in dermatology. However, the specific details of what changed cannot be determined from the provided policy metadata alone.
High impact
OTC drug exclusion reminder and SGLT2 inhibitor update
Harvard Pilgrim Health Care·Effective Oct 1, 2026
Point32Health is implementing two major pharmacy coverage changes: (1) Effective Oct 1, 2026, excluding coverage for OTC drugs and prescription equivalents (antihistamines, H2 blockers, nasal steroids, fluoride, PPIs) except pediatric formulations and ACA-mandated drugs; (2) Effective Nov 15, 2026, moving all brand-name SGLT2 inhibitors to non-formulary status for Commercial large group plans, with automatic generic substitution for Farxiga and Xigduo XR, and prior authorization required for members on other brand names.
Medium impact
MassHealth managed care enrollment update
Harvard Pilgrim Health Care·Effective Aug 1, 2026
MassHealth is transitioning some members from managed care health plans to the MassHealth fee-for-service (FFS) program effective August 1, 2026 and December 1, 2026. Affected members remain eligible for MassHealth but will now be covered under FFS instead of a managed care plan. Billing teams must verify member eligibility in the MassHealth Eligibility Verification System and ensure the practice is enrolled as a fully participating MassHealth provider to bill FFS members.
High impact
Medi-Cal Fee-for-Service Transition for UIS Members
Medi-Cal·Effective Jan 1, 2027
Beginning January 1, 2027, Medi-Cal members with Unsatisfactory Immigration Status (UIS) will transition from managed care to fee-for-service Medi-Cal. Providers must enroll in Medi-Cal fee-for-service billing, update PAVE enrollment, and comply with fee-for-service billing requirements including Treatment Authorization Requests (TARs) to continue serving these members after December 31, 2026.
Medium impact
Watch for Digital Access to Medicare Advantage Prior Authorization Decision Letters via Availity® Essentials
BCBS Oklahoma·Effective Oct 8, 2026
Blue Cross Blue Shield of Oklahoma is transitioning prior authorization approval letters for Medicare Advantage members to digital-only access via Availity Essentials starting October 8, 2026, with mail cessation on December 11, 2026. Denial letters will continue via USPS but will also be available digitally. Providers must begin monitoring Availity Essentials for prior authorization decisions instead of relying on postal mail.
Medium impact
Drug Policy Criteria Change
Arkansas Blue Cross Blue Shield·Effective Sep 27, 2026
This policy updates drug coverage criteria for three medications: Opdivo now covers combination use with Tudriqev for cutaneous melanoma (effective 09/27/2026), Zolymbus is added to the target drug list while Lumigan is removed due to generic availability (effective 10/01/2026). Billing teams must update formulary references and prior authorization rules accordingly.
High impact
Policy Criteria Change
Arkansas Blue Cross Blue Shield·Effective Nov 15, 2026
Arkansas Blue Cross is removing a previous non-coverage statement for steroid injections into facet joints, effectively reversing a blanket denial and making these procedures potentially coverable under Primary Coverage Criteria. Billing teams must immediately stop denying facet joint steroid injection claims based on the old non-coverage policy and begin processing them according to individual member benefit certificates and medical necessity determinations.
Low impact
New: Availity Essentials to Sharpen Your Skills
Ambetter·Identified Sep 12, 2026
AmBetter Health is announcing free training resources through the Availity Learning Center to help providers optimize use of Availity Essentials platform. This is an informational bulletin about available educational webinars and on-demand training, not a policy change affecting billing, coding, or claims processing.
Low impact
New to Availity Essentials or looking to sharpen your skills?
Ambetter·Identified Sep 12, 2026
This is an informational bulletin from AmBetter Health announcing available training resources for Availity Essentials, including live webinars scheduled for August and October 2026 covering pre-service and post-service workflows. No billing policy or procedure changes are implemented by this bulletin.
Low impact
New to Availity Essentials or looking to sharpen your skills?
Ambetter·Identified Sep 12, 2026
Availity Essentials is offering new training resources for providers through the Availity Learning Center, including live webinars on pre-service and post-service workflows scheduled for October 6-8, 2026. This is an informational bulletin announcing optional training opportunities rather than a policy change affecting billing, coding, or claims processing.
Low impact
New to Availity Essentials or looking to sharpen your skills?
Ambetter·Identified Sep 12, 2026
This is an informational bulletin from Availity/AmBetter Health announcing training resources and live webinars for providers using Availity Essentials. Two live webinars are scheduled for October 2026 covering pre-service workflows (October 6) and post-service workflows (October 8). No billing or coverage policy changes are implemented.
Low impact
New to Availity Essentials or looking to sharpen your skills?
Ambetter·Identified Sep 12, 2026
Availity Essentials is offering new training resources to help providers optimize their use of the platform. This is an informational bulletin announcing live webinars in October (pre-service workflow on 10/6 and post-service workflow on 10/8) and on-demand training through the Availity Learning Center. No billing workflow, coding, or coverage changes are required.
Low impact
New to Availity Essentials or looking to sharpen your skills?
Ambetter·Identified Sep 12, 2026
Availity is promoting training resources for providers using Availity Essentials, including live webinars scheduled for October 6-8, 2026 covering pre-service and post-service workflows. This is an informational bulletin directing billing staff to access learning materials through the Availity Learning Center to improve operational efficiency with the platform.
Low impact
New to Availity Essentials or looking to sharpen your skills?
Ambetter·Identified Sep 12, 2026
This is an informational bulletin from Availity announcing training resources and live webinars for providers using Availity Essentials. The bulletin promotes access to the Availity Learning Center with flexible training options (live webinars, on-demand training) and highlights two specific live webinar sessions scheduled for October 2026 covering pre-service and post-service workflows.
Low impact
New to Availity Essentials or looking to sharpen your skills?
Ambetter·Identified Sep 12, 2026
This is an informational bulletin from Availity announcing training resources and live webinars (October 6 and 8) to help providers learn Availity Essentials platform features, including pre-service workflows (eligibility, benefits, authorizations) and post-service workflows (claim submission, EDI reporting, claim status, remittance). No billing process, code, or coverage changes are mandated.
Medium impact
New Functionality in Availity Essentials
Ambetter·Identified Sep 12, 2026
Availity Essentials has launched three new features for providers in this region: (1) extended eligibility lookups up to 30 days in advance for Medicare and Medicaid, (2) increased attachment file sizes to 64 MB per file (max 10 files) for claim appeal submissions to Sunflower Health Plan, and (3) streamlined authorization follow-ups by viewing and responding to Requests for Additional Information (RFAI) directly within the portal. Billing teams must familiarize staff with these new tools to improve workflow efficiency and reduce manual authorization follow-up processes.
Medium impact
New Payment Policy: Problem-Oriented Visits with Surgical Procedure (CC.PP.052) & Problem-Oriented Visits with Preventative Visits (CC.PP.057)
Ambetter·Effective Sep 19, 2026
Ambetter from MHS Indiana has announced new payment policies (CC.PP.052 and CC.PP.057) governing reimbursement for problem-oriented visits combined with surgical procedures and preventative visits. The policy becomes effective 9/19/2026 and requires billing teams to validate that their coding and billing workflows align with the updated guidance to ensure compliant claims processing.
Medium impact
New or Updated Policies – Effective October 6, 2026
Ambetter·Effective Oct 6, 2026
MHS Health Indiana (Ambetter) is implementing a new Clinical Policy with Payment Edit for Allergy Testing and Therapy (CP.MP.100) effective October 6, 2026. The billing team must review the full policy details on the Ambetter provider portal to identify specific billing code changes, prior authorization requirements, or payment edits that will affect allergy-related claims for Indiana marketplace members.
Low impact
New to Availity Essentials or looking to sharpen your skills?
Ambetter·Identified Sep 12, 2026
This is an informational bulletin from AmBetter Health announcing training opportunities through the Availity Learning Center. The bulletin promotes live webinars and on-demand training for providers using Availity Essentials, with specific sessions scheduled for August and October covering pre-service workflows (eligibility, benefits, authorizations) and post-service workflows (claim submission, EDI reporting, claim status, remittance viewing). No billing process, coverage, or reimbursement changes are implemented by this policy.
Low impact
New to Availity Essentials or looking to sharpen your skills?
Ambetter·Identified Sep 12, 2026
Availity is announcing training resources and live webinars to help providers learn Availity Essentials platform features and workflows. This is an informational bulletin about available educational opportunities, not a policy change affecting billing, coding, or claims processing.

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Archive by year

2023 2024 2025 2026

AHCCCS Seeks Public Comment on HCBS Needs Tool (HNT) and Extraordinary Care Review (ECR) Rulemaking

Patient Lifts (e.g., Hoyer, Saralift, Seat Lift, Chair Mechanisms, and Ceiling Lifts) 1.01.08

Patient Lifts - (Effective Date - 2026-11-16) 1.01.08

MA08.098b, Tildrakizumab-asmn (Ilumya®)

MA08.086e, Nusinersen (Spinraza®)

08.01.48c, Tildrakizumab-asmn (Ilumya®)

OTC drug exclusion reminder and SGLT2 inhibitor update

MassHealth managed care enrollment update

Medi-Cal Fee-for-Service Transition for UIS Members

Watch for Digital Access to Medicare Advantage Prior Authorization Decision Letters via Availity® Essentials

Drug Policy Criteria Change

Policy Criteria Change

New: Availity Essentials to Sharpen Your Skills

New to Availity Essentials or looking to sharpen your skills?

New to Availity Essentials or looking to sharpen your skills?

New to Availity Essentials or looking to sharpen your skills?

New to Availity Essentials or looking to sharpen your skills?

New to Availity Essentials or looking to sharpen your skills?

New to Availity Essentials or looking to sharpen your skills?

New to Availity Essentials or looking to sharpen your skills?

New Functionality in Availity Essentials

New Payment Policy: Problem-Oriented Visits with Surgical Procedure (CC.PP.052) & Problem-Oriented Visits with Preventative Visits (CC.PP.057)

New or Updated Policies – Effective October 6, 2026

New to Availity Essentials or looking to sharpen your skills?

New to Availity Essentials or looking to sharpen your skills?