All Insurance Policy Changes (Page 37)

Continuing from page 36. 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
Coming October 2026: Third Quarter HCPCS Updates to Texas Medicaid Procedure Codes
Texas Medicaid·Effective Oct 1, 2026
Effective October 1, 2026, Texas Medicaid will implement HCPCS procedure code updates (additions, revisions, and discontinuations) from CMS. Discontinued codes will no longer be covered; added codes require HHSC rate hearing approval before reimbursement begins, though clinician-administered drug codes may be reprocessed back to the CMS effective date once rates are implemented. Billing teams must monitor for code changes and coordinate with MCOs regarding administrative procedures.
High impact
Coming October 2026: Third Quarter HCPCS Updates to CSHCN Services Program Procedure Codes
Texas Medicaid·Effective Oct 1, 2026
Effective October 1, 2026, Texas Medicaid will implement HCPCS procedure code updates for the CSHCN Services Program, including additions, revisions, and discontinuations. Discontinued codes will no longer be covered benefits. New codes will not be reimbursed until HHSC completes rate hearings and notifies providers of benefit changes.
High impact
2026-08-06 - Readout: CMS Celebrates Delivery of the Health Technology Ecosystem, One Year After Launch
Medicare/CMS·Identified Aug 6, 2026
This MLN Connects newsletter (August 6, 2026) contains multiple actionable updates for medical billing teams: (1) SNF VBP Program expanded from 4 to 8 quality measures for FY 2027 with August 30 correction deadline; (2) Home Health Agencies must download 2025 PEPPER reports to identify billing pattern issues; (3) Global Surgery postoperative visit reporting is now required in 9 specific states for practices with 10+ providers; (4) Glucose monitoring supplies have a 25.2% improper payment rate—billing corrections are critical to prevent claim denials.
High impact
26-989 Changes to Community Supports Services, Effective January 1, 2027
Health Net·Effective Jan 1, 2027
Effective January 1, 2027, Health Net will discontinue three Community Supports services: Assisted Living Facility Transitions, Personal Care and Homemaker Services, and Short-Term Post-Hospitalization Housing. Providers must identify affected members, continue services through December 31, 2026, and coordinate care transitions. This impacts Medi-Cal in 10 California counties.
High impact
26-991 Changes to Community Supports Services, Effective January 1, 2027
Health Net·Effective Jan 1, 2027
Effective January 1, 2027, Community Health Plan of Imperial Valley is terminating three Community Supports services: Assisted Living Facility Transitions, Personal Care and Homemaker Services, and Short-Term Post-Hospitalization Housing. The billing team must identify all affected members currently receiving these services, ensure services end by December 31, 2026, and coordinate care transitions to avoid service gaps.
High impact
26-990 Changes to Community Supports Services, Effective January 1, 2027
Health Net·Effective Jan 1, 2027
CalViva Health is discontinuing three Community Supports services effective January 1, 2027: Assisted Living Facility Transitions, Personal Care and Homemaker Services, and Short-Term Post-Hospitalization Housing. Billing teams must identify affected members, ensure services end by December 31, 2026, and coordinate transition planning to avoid service gaps and claim denials.
High impact
Medical Policy and Coding Updates - August 2026
Premera Blue Cross·Effective Nov 15, 2026
This comprehensive August 2026 policy update from Carelon Medical Benefits Management affects genetic testing, somatic tumor testing, radiation oncology, and antipsychotic medications effective November 15, 2026. Major changes include expanded coverage for liquid biopsy testing in multiple cancer types, new non-medical necessity designations for specific tests, revised radiation oncology guidelines for non-malignant conditions, and updated criteria for hematologic malignancy testing. Billing teams must update prior authorization requirements, coverage determination logic, and clinical appropriateness screening across oncology, genetic testing, and radiation oncology services.
Medium impact
Authorization Updates - Effective September 1, 2026
Sentara Health Plans·Effective Sep 1, 2026
Effective September 1, 2026, Sentara Health Plans will no longer require prior authorization for four vaccine administration codes (90587, 90649, 90668, 90739) across all Commercial products in Virginia. Billing teams must update authorization workflows to remove these codes from prior auth requirements to prevent unnecessary claim delays.
High impact
Policy Criteria Change
Arkansas Blue Cross Blue Shield·Effective Oct 7, 2026
This policy updates coverage criteria for Axicabtagene Ciloleucel (Yescarta), a CAR T-cell therapy, to align with current FDA labeling and NCCN guidelines. The policy now covers two FDA-labeled indications (large B-cell lymphoma and follicular lymphoma) plus thirteen off-label indications, with specific eligibility requirements including prior therapy history, organ/bone marrow function assessment, and a lifetime limit of one administration per patient.
High impact
[Ohio] Ohio Medicaid Managed Care and Anthem MyCare Ohio: ASC claims accepted on CMS-1500 and UB-04 — resubmit denied claims
Anthem BCBS·Effective Aug 3, 2026
Anthem has updated its claims system to accept ASC (ambulatory surgery center) claims on both CMS-1500 and UB-04 forms. Previously denied claims due to incorrect billing form should be resubmitted. This resolves a systemic configuration error that was causing claim denials based on form type.
Medium impact
[Ohio] Simplifying MSK care with the HOPCo Digital Clinic
Anthem BCBS·Effective Aug 3, 2026
Anthem Blue Cross and Blue Shield in Ohio is launching the HOPCo Digital Clinic, a virtual-first musculoskeletal (MSK) care program that provides early access to MSK evaluations within 24-48 hours for eligible commercial members. PCPs and MSK specialists should recognize this as a new care pathway option for non-urgent MSK conditions, which may affect referral patterns and coordination workflows but does not introduce new billing codes or change existing reimbursement.
High impact
[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
Anthem BCBS·Effective Nov 15, 2026
Carelon Medical Benefits Management updated clinical appropriateness guidelines effective November 15, 2026, with significant changes to coverage criteria for vascular procedures, genetic testing, and cancer-related molecular testing. Key changes include new indications for drug-eluting beads in liver cancer treatment, expanded genetic testing criteria for multiple cancer types, new allowances for cyanoacrylate ablation in varicose vein treatment, and exclusion of certain procedures (PFO closure in patients >60 years, ctHPV DNA testing in oropharyngeal carcinoma, and immunoembolization therapy). Billing teams must update prior authorization workflows and claims adjudication rules to reflect these additions and deletions.
Medium impact
Narrow Network Claims – Remittance Info Now Available for All Participating Providers
Highmark·Effective Aug 4, 2026
Highmark now provides narrow network claim remittance information visible to ALL participating providers in Availity Essentials, regardless of whether those providers participate in narrow networks. This enables providers to view claim processing details and expedite account receivable updates and patient billing without individual member lookups.
High impact
Revalidate early to avoid last-minute delays
Geisinger Health Plan·Identified Aug 5, 2026
Pennsylvania Medicaid and CHIP providers must complete state enrollment revalidation early to avoid year-end processing delays that could interrupt claims payment and provider participation. This is a proactive notification to submit revalidation documentation before the deadline rush impacts GHP Family (Medicaid) and GHP Kids (CHIP) members.
High impact
High-dollar claims and split billing requirements
Geisinger Health Plan·Identified Aug 5, 2026
Geisinger Gold (Medicare Advantage) now requires claims exceeding $99,999.99 to be split into multiple submissions with modifier 76 on subsequent claims and specific narrative documentation. High-cost services like drugs, hemophilia clotting factors, and skin substitutes must follow strict split-billing procedures to avoid rejections and duplicate denials.
High impact
Home Health Care Services MNG updates
Harvard Pilgrim Health Care·Effective Oct 1, 2026
Point32Health is creating a new Medical Necessity Guideline (MNG) specific to Tufts Health Together members effective October 1, 2026, while splitting the existing MNG into separate guidelines for Tufts Health RITogether and Tufts Health One Care. The new guideline eliminates prior authorization requirements for RN and LPN/LVN services (HCPCS codes T1002 and T1003) but requires prior authorization for intermittent skilled nursing and medication-assisted visits when services exceed 30 visits in a calendar year, with specific documentation requirements.
Medium impact
Nuedexta® (dextromethorphan and quinidine) (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has revised its prior authorization policy for Nuedexta® (dextromethorphan/quinidine) effective January 1, 2022, with a revision dated March 25, 2026. The policy requires prior authorization for this medication used to treat Pseudobulbar Affect (PBA) and mandates that providers attest that QT prolongation risks have been considered and treatment benefits outweigh risks. This is a pharmacy coverage policy affecting Medicare Advantage members only.
Medium impact
First Quarter 2026
Molina Healthcare·Identified Aug 5, 2026
Molina Healthcare of Utah Q1 2026 newsletter updates providers on Medicare Stars resources, quality performance metrics (HEDIS and CAHPS), and establishes mandatory provider data validation requirements. Providers must validate all practice information through CAQH every 90 days or face removal from the provider directory, and must notify Molina of any changes within 30 days.
Medium impact
Second Quarter 2026
Molina Healthcare·Identified Aug 5, 2026
Molina Healthcare of Utah released a Q2 2026 provider newsletter containing multiple operational updates. Key billing-related changes include: (1) New EFT/ERA enrollment through ECHO Health with SSI Group, offering virtual card, ACH, check, or EFT payment options; (2) Launch of Molina Care Connections with nurse practitioner-delivered services at $0 member cost across 22 states; (3) Clarification of utilization management criteria and decision-making processes. The practice must update systems to accept SSI Group payer ID for ERAs and coordinate with Molina Care Connections to avoid duplicate billing.
High impact
Updates to Rate Increase for Personal Care Services and the Community Alternatives Program
NC Medicaid - NCDHHS·Effective Aug 1, 2026
Effective August 1, 2026, NC Medicaid is applying an 18% rate increase across all Personal Care Services (PCS) procedure codes for NC Medicaid Direct, CAP/C, CAP/DA, and CAP/CD programs. This replaces the previous July 31, 2026 bulletin and also applies to PCS furnished through NC Medicaid Managed Care (Standard Plans and Tailored Plans). Billing teams must update fee schedules in their systems and ensure claims reflect the new rates.
Low impact
CDPHP Names Brian Sheridan, MD, Regional Chief Medical Officer
CDPHP·Effective Sep 1, 2026
CDPHP announced a leadership change with Dr. Brian Sheridan assuming the role of Regional Chief Medical Officer effective September 2026, succeeding Dr. Bruce Coplin. This is an administrative organizational announcement with no direct impact on billing codes, coverage policies, or claims processing procedures.
High impact
September 2026 TMPPM Update for Hearing Aid Services
Texas Medicaid·Effective Sep 1, 2026
Effective September 1, 2026, TMHP is updating hearing aid services billing rules to deny claims for procedure codes 92628 and 92631 when submitted on the same date of service for the same ear as specific conflicting procedure codes. This creates new claim denial triggers that billing staff must monitor to avoid rejected claims.
Low impact
Writing Acceptable Plans of Correction for HCS and TxHmL Providers In-Person Training
Texas Medicaid·Effective Aug 6, 2026
HHSC Long-Term Care Regulation is hosting a mandatory in-person training event on August 6, 2026, for HCS (Home and Community-based Services) and TxHmL (Texas Home and Living) providers. The training covers writing acceptable Plans of Correction and the Informal Dispute Resolution process. This is an educational/compliance training event, not a billing policy change, but attendance may be required for regulatory compliance at these provider types.
High impact
REMINDER: ICF UPL Program IGT Notification – FFY 2026, 3rd Quarter
Texas Medicaid·Effective Aug 5, 2026
HHSC is notifying ICF/IID providers of the FFY 2026 3rd Quarter IGT (Intergovernmental Transfer) payment requirements. Providers must schedule and transfer IGT funds through TexNet by August 5, 2026, with settlement on August 6 and expected payment release by August 17, 2026. IGT amounts are specified in Column K of the Q3 Summary Original tab on the ICF UPL Supplemental Payment Program website.
Low impact
Update to “TMHP to Publish Off-Cycle Static Fee Schedule on July 28, 2026”
Texas Medicaid·Effective Jul 29, 2026
TMHP published the off-cycle static fee schedule on July 29, 2026 (not July 28, 2026 as originally announced). This is a clarification of the publication date only. Billing teams should access the corrected fee schedule from the TMHP Static Fee Schedules web page and verify current reimbursement rates for Texas Medicaid MCO claims.

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2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 37) | PolicyChanges.app

Coming October 2026: Third Quarter HCPCS Updates to Texas Medicaid Procedure Codes

Coming October 2026: Third Quarter HCPCS Updates to CSHCN Services Program Procedure Codes

2026-08-06 - Readout: CMS Celebrates Delivery of the Health Technology Ecosystem, One Year After Launch

26-989 Changes to Community Supports Services, Effective January 1, 2027

26-991 Changes to Community Supports Services, Effective January 1, 2027

26-990 Changes to Community Supports Services, Effective January 1, 2027

Medical Policy and Coding Updates - August 2026

Authorization Updates - Effective September 1, 2026

Policy Criteria Change

[Ohio] Ohio Medicaid Managed Care and Anthem MyCare Ohio: ASC claims accepted on CMS-1500 and UB-04 — resubmit denied claims

[Ohio] Simplifying MSK care with the HOPCo Digital Clinic

[Virginia] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines

Narrow Network Claims – Remittance Info Now Available for All Participating Providers

Revalidate early to avoid last-minute delays

High-dollar claims and split billing requirements

Home Health Care Services MNG updates

Nuedexta® (dextromethorphan and quinidine) (Revised)

First Quarter 2026

Second Quarter 2026

Updates to Rate Increase for Personal Care Services and the Community Alternatives Program

CDPHP Names Brian Sheridan, MD, Regional Chief Medical Officer

September 2026 TMPPM Update for Hearing Aid Services

Writing Acceptable Plans of Correction for HCS and TxHmL Providers In-Person Training

REMINDER: ICF UPL Program IGT Notification – FFY 2026, 3rd Quarter

Update to “TMHP to Publish Off-Cycle Static Fee Schedule on July 28, 2026”