All Insurance Policy Changes (Page 4)

Continuing from page 3. 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
[New York] 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 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 its vendor partners. The review processes remain consistent, with efforts to minimize duplicate medical record requests.
High impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (August 2026 Newsletter)
Anthem BCBS·Effective Oct 1, 2026
Carelon Medical Benefits Management has issued multiple prior authorization requirement updates across multiple service categories (Genetic Testing, Surgical, DME/POS, Cardiology, Radiation Therapy, Sleep, Radiation Oncology, and Cardiovascular services) effective at staggered dates between October 1, 2026 and December 1, 2026. These are material amendments to contract terms affecting Commercial, Medicare Advantage, Medicaid, and MyCare Ohio plans in Ohio. The practice must review detailed policy documents for each specialty to identify specific code-level changes and implement corresponding prior authorization workflows.
High impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (August 2026 Newsletter)
Anthem BCBS·Effective Nov 1, 2026
Carelon Medical Benefits Management has issued multiple precertification/prior authorization requirement updates effective November 1, 2026 and December 1, 2026 across multiple service categories (Genetic Testing, Cardiology, Radiation Oncology, Base Surgical, DMEPOS, Radiology, and Radiation Therapy) for Virginia providers. The policy affects Commercial, Medicare Advantage, and Medicaid plan types and requires billing teams to verify and implement updated prior authorization protocols for affected services.
Low impact
Cigna Healthcare Expands Personalized Care Management to Help More Customers Access Support Earlier
Cigna·Identified Jul 29, 2026
Cigna Healthcare is expanding its care management program to reach 20% more customers through AI-enabled predictive analytics for earlier identification and engagement. This is an informational announcement about enhanced care coordination and outreach capabilities; no billing code changes, coverage restrictions, or prior authorization requirements are specified.
High impact
Change in Coverage for PEBTF Members
Geisinger Health Plan·Effective Jan 1, 2026
Effective January 1, 2026, PEBTF health coverage transitions from Geisinger Health Plan (GHP) to Aetna's Custom HMO plan. All claims for PEBTF members with dates of service after December 31, 2025, must be submitted to Aetna, not GHP. Claims submitted to GHP for 2026 services will be denied due to coverage termination.
High impact
GHP provider portal transition to Availity Essentials
Geisinger Health Plan·Effective Jan 1, 2026
Geisinger Health Plan (GHP) is migrating all provider portal functions from NaviNet to Availity Essentials, with exclusive access through Availity Essentials beginning January 1, 2026. All GHP functions (claims status, eligibility, PCP inquiries, HEDIS dashboards) will move to the new platform, though secure messaging will not be immediately available. Your organization must register with Availity Essentials and designate an administrator before the deadline.
High impact
Special Enrollment Period for Geisinger Gold and Medicare Advantage patients
Geisinger Health Plan·Effective Jan 1, 2026
Geisinger Health Plan is discontinuing the Preferred Enhanced Rx (PPO) Medicare Advantage plan statewide and reducing Classic 360 Rx (HMO) coverage to exclude 11 Pennsylvania counties effective January 1, 2026. Affected members must enroll in a new Medicare Advantage plan by December 31, 2025, or coverage will revert to Original Medicare with loss of prescription drug benefits. A Special Enrollment Period is available through February 28, 2026.
Medium impact
Long-acting reversible contraceptive alternative payment methodology
Geisinger Health Plan·Identified Jul 29, 2026
Geisinger Health Plan now provides supplemental payment under the Pennsylvania Department of Human Services Medical Assistance (MA) alternative payment methodology (APM) for long-acting reversible contraceptive (LARC) device insertion and removal at federally qualified health centers (FQHCs) and rural health clinics (RHCs). This supplemental payment offsets high device costs and allows same-visit insertion/removal for MA beneficiaries.
High impact
Multiplex respiratory pathogen panel coverage
Geisinger Health Plan·Effective Apr 1, 2025
Geisinger Health Plan is restricting coverage of CPT code 0202U (BioFire FilmArray Respiratory Panel 2.1) effective April 1, 2025. The multiplex respiratory pathogen panel will only be covered for patients in observation and inpatient status—not for outpatient or emergency department testing. This change applies to all Geisinger plans including Medicare Advantage and Medicaid, and will shift significant out-of-pocket costs to members seeking respiratory testing in office or ED settings.
High impact
Geisinger Gold aligns with Medicare regulations for home infusion therapy billing
Geisinger Health Plan·Effective Jan 1, 2026
Effective January 1, 2026, Geisinger Gold (Medicare Advantage) will no longer pay for S and 99 codes billed for home infusion therapy administration. Providers must align with Medicare standards by billing professional services under the Medicare home infusion therapy benefit (requiring External Infusion Pump LCD L33794 compliance) instead. Claims submitted with S or 99 codes on or after this date will deny as provider liability.
High impact
Changes to authorization Daily Inpatient Fax Report
Geisinger Health Plan·Effective Feb 1, 2026
Effective February 1, 2026, Geisinger Health Plan is discontinuing the Daily Inpatient Fax Report for prior authorization status updates. All authorization details, including status checks, review dates, readmission information, and discharge documentation, will now be accessed exclusively through the Cohere Portal. The billing team must transition from fax-based reporting to real-time portal access.
Medium impact
Coding and Cost Analysis Unit and pre-payment claim editing
Geisinger Health Plan·Identified Jul 29, 2026
Failed to analyze policy change
High impact
GHP Family high-cost drug billing policy
Geisinger Health Plan·Identified Jul 29, 2026
GHP Family has established new billing requirements for high-cost drugs (FDA-approved cellular and gene therapy products), including mandatory use of Revenue Code 636, HCPCS codes, NDC reporting on all claims, and specific form submission rules (837 Institutional, CMS-1500, or UB-04). For sickle cell disease therapies (Lyfgenia and Casgevy), reimbursement requires inpatient administration and CIBMTR registry participation.
Medium impact
Long-acting reversible contraception
Geisinger Health Plan·Identified Jul 29, 2026
Geisinger Health Plan (GHP) now reimburses hospitals separately for long-acting reversible contraception (LARC) devices—intrauterine devices and contraceptive implants—provided immediately postpartum to GHP Family Medicaid patients, in addition to the standard APR-DRG obstetrical delivery payment. Billing teams must submit LARC claims using outpatient hospital claim format with appropriate procedure codes and modifiers from the Medicaid fee schedule.
High impact
No balance billing for Geisinger Gold Secure Rx patients
Geisinger Health Plan·Effective Jan 11, 2024
Geisinger Gold Secure Rx (a Medicare Advantage plan with integrated Medicaid) prohibits balance billing members for any amounts not covered by the plan. Billing teams must write off all patient balances after Geisinger Gold payment and may bill Medicaid as secondary without requiring Medicaid participation.
Medium impact
Geisinger Gold Secure Rx (HMO D-SNP) members and Community HealthChoices
Geisinger Health Plan·Effective Jan 18, 2024
Geisinger Gold Secure Rx (HMO D-SNP) members who have Community HealthChoices (CHC) as secondary Medicaid coverage can continue receiving care from all Geisinger providers for Medicare-covered services. Geisinger providers do not need CHC MCO participation to bill them as secondary insurers, and members do not need to switch their primary Medicare Advantage coverage to CHC. This clarifies billing and provider access for dual-eligible beneficiaries in Pennsylvania.
High impact
New Cohere sleep management program aims to improve quality and reduce member cost
Geisinger Health Plan·Effective Feb 16, 2026
Effective February 16, 2026, Geisinger Health Plan (GHP) now requires prior authorization through Cohere Health for all facility-based sleep studies. At-home sleep studies remain exempt from prior authorization. Billing teams must route all facility-based sleep study requests through the Cohere Health provider portal to avoid claim denials.
High impact
Billing update for FQHCs and RHCs
Geisinger Health Plan·Effective Mar 1, 2025
Effective March 1, 2025, FQHCs and RHCs can no longer bill T1015 (Clinic Visit/Encounter, All-Inclusive) as a standalone code. Claims must now include a qualifying E/M or HCPCS service code describing the actual services provided. T1015-only claims will be denied with CARC 129/RARC 130 and are non-appealable unless resubmitted with complete information.
Low impact
New Geisinger Health Plan president named
Geisinger Health Plan·Effective Feb 23, 2026
Jeremy Gaskill has been appointed as the new president of Geisinger Health Plan (GHP) and executive vice president of insurance operations for Geisinger, effective February 23, 2026. This is a leadership change at the plan level that may affect future policy decisions, billing processes, and provider relations, but does not immediately change current billing requirements or procedures.
High impact
Community Health Worker (CHW) billing update
Geisinger Health Plan·Effective Jan 1, 2026
Effective January 1, 2026, GHP Family now allows certified Community Health Workers (CHWs) to bill for services using procedure code G0019 at $27.98 per unit, limited to 3 visits per member per year. CHWs must obtain Pennsylvania certification, PROMISe ID enrollment, and DHS enrollment at each service location. Billing team must implement new code workflows, documentation requirements, and visit limits to ensure compliance.
High impact
Billing procedures for physical health Targeted Case Management (TCM) services
Geisinger Health Plan·Effective Oct 12, 2025
Effective October 12, 2025, Pennsylvania Medicaid (GHP Family) now covers Targeted Case Management (TCM) services for juveniles transitioning from carceral settings using procedure code G9012 with mandatory TF modifier. Billing team must use G9012 + TF modifier for all physical health TCM claims; claims without the TF modifier will not process correctly. Behavioral health TCM services route to county-based BH-MCOs separately.
Low impact
Health equity reporting
Geisinger Health Plan·Effective Mar 5, 2026
Geisinger Health Plan is implementing health equity reporting as a regulatory requirement and transparency initiative. The plan has published a prior authorization report for Medicare Advantage beneficiaries, available on their Medicare benefit documents page. This policy requires billing teams to be aware of and potentially reference equity reporting data in their interactions with Geisinger Gold Medicare Advantage plans.
Low impact
Enhanced call center experience coming soon to better support providers
Geisinger Health Plan·Effective May 1, 2026
Geisinger Health Plan is launching an enhanced IVR (interactive voice response) system in early spring 2026 that will streamline provider call center access through conversational routing, upfront identity verification, and new self-service tools for eligibility, benefits, and claims status. Billing teams will interact with a modernized call experience that reduces transfer times and improves call routing accuracy.
Low impact
Healthy Connections Medicaid Provider Training Opportunities August-October 2026
SC Medicaid - SCDHHS·Effective Aug 4, 2026
The South Carolina Department of Health and Human Services (SCDHHS) is offering free Healthy Connections Medicaid provider training opportunities from August through October 2026. In-person workshops have transitioned back from virtual to in-person format at the BlueCross BlueShield South Carolina-Government Programs Complex in Columbia, SC, covering topics including Medicaid basics, web-based claims submission tools, claim-level adjustments, TPL processes, ORP enrollment requirements, and managed care enrollment.
High impact
Every Reading Counts: Your Contribution to Better Blood Pressure Outcomes
Florida Blue·Effective Jul 1, 2026
Florida Blue has issued updated guidance on blood pressure management documentation and coding for HEDIS reporting. Providers must now document exact blood pressure readings (no rounding or ranges), utilize specific CPT II codes (3074F-3080F) based on systolic/diastolic thresholds, and assign appropriate ICD-10 codes for hypertensive conditions. This change emphasizes detailed documentation to support quality measure compliance and care management targeting.

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Archive by year

2023 2024 2025 2026

[New York] Continued collaboration on DRG clinical and coding validation

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

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

Cigna Healthcare Expands Personalized Care Management to Help More Customers Access Support Earlier

Change in Coverage for PEBTF Members

GHP provider portal transition to Availity Essentials

Special Enrollment Period for Geisinger Gold and Medicare Advantage patients

Long-acting reversible contraceptive alternative payment methodology

Multiplex respiratory pathogen panel coverage

Geisinger Gold aligns with Medicare regulations for home infusion therapy billing

Changes to authorization Daily Inpatient Fax Report

Coding and Cost Analysis Unit and pre-payment claim editing

GHP Family high-cost drug billing policy

Long-acting reversible contraception

No balance billing for Geisinger Gold Secure Rx patients

Geisinger Gold Secure Rx (HMO D-SNP) members and Community HealthChoices

New Cohere sleep management program aims to improve quality and reduce member cost

Billing update for FQHCs and RHCs

New Geisinger Health Plan president named

Community Health Worker (CHW) billing update

Billing procedures for physical health Targeted Case Management (TCM) services

Health equity reporting

Enhanced call center experience coming soon to better support providers

Healthy Connections Medicaid Provider Training Opportunities August-October 2026

Every Reading Counts: Your Contribution to Better Blood Pressure Outcomes