All Insurance Policy Changes (Page 5)

Continuing from page 4. 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
26-1042 Route Covered DME and Home Respiratory Services Referrals to Apria
Health Net·Identified Sep 12, 2026
Health Net now requires all covered DME and home respiratory services referrals to be routed exclusively to Apria Healthcare, their preferred contracted provider. Shared-risk PPGs that refer DME to other suppliers may face capitation payment deductions. Billing teams must immediately update referral workflows and staff procedures to direct all eligible DME and respiratory service referrals to Apria via fax (888-492-0010) or phone (888-492-7742).
High impact
26-1061sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk
Health Net·Effective Nov 17, 2026
Health Net California has updated the Injectable Medication HCPCS/DOFR (Division of Financial Responsibility) Crosswalk effective November 17, 2026, adding 11 new injectable medications, 15 new biosimilars, 6 new generic medications, and making 27 updates to existing codes with 3 DOFR categorization corrections. Billing teams must obtain and implement the complete crosswalk update (26-1061) to ensure accurate claims processing and proper financial responsibility assignments for injectable medications.
High impact
26-1062sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk
Health Net·Effective Nov 17, 2026
Health Net/Community Health Plan of Imperial Valley updated the Injectable Medication HCPCS/DOFR Crosswalk effective November 17, 2026, adding 11 new injectable medications, 15 new biosimilars, 6 new generic medications, and making 27 updates to existing codes, plus 3 DOFR categorization corrections. Billing teams must obtain and implement the complete crosswalk update (26-1062) to ensure accurate coding and financial responsibility assignment for all injectable medication claims.
High impact
26-1060sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk
Health Net·Effective Nov 17, 2026
Health Net's Pharmacy Advisory Committee has updated the Injectable Medication HCPCS/DOFR Crosswalk effective November 17, 2026, adding 11 new injectable medications, 15 new biosimilars, 6 new generic medications, and making 27 updates to existing codes. The update includes 3 DOFR categorization corrections, 2 administrative changes, and 21 code description updates that will affect how injectable medications are billed and assigned to financial responsibility categories under the Health Net Provider Participation Agreement.
Medium impact
Updated Preventive Coverage for Colorectal Cancer Screening to add SimpleScreen™ CRC for Medicare Advantage Members (Effective July 24, 2026)
Independence Blue Cross·Effective Jul 24, 2026
Medicare Advantage plans are adding SimpleScreen™ CRC (a noninvasive colorectal cancer screening test) to their preventive coverage effective July 24, 2026. This expands covered screening options for MA members and may affect billing for colorectal cancer screening services.
Medium impact
Referral Coordination for Certain Institutional Settings for Medical Day Care Services Waiver
Maryland Medicaid·Effective Mar 16, 2026
Maryland Medical Assistance Program has implemented mandatory case management agency (CMA) coordination for Medical Day Care Services Waiver (MDCSW) referrals from institutional settings. Discharge planners from hospitals and nursing facilities must now complete a new 3871B form workflow, inform patients of CMA selection requirements, and notify MDH of enrollment requests via specific email format. All MDCSW participants require assignment to one of five authorized CMAs based on their residential jurisdiction.
High impact
Medicare Enrollment Requirement for High Risk-Provider Types
Maryland Medicaid·Identified Sep 11, 2026
Maryland Medicaid now requires all Diabetes Prevention Program providers and Nursing Facilities (high-risk provider types) to maintain active Medicare enrollment. Providers must submit proof of active Medicare enrollment during their next Medicaid revalidation, Change of Ownership application, or initial enrollment application. Failure to provide this documentation will result in application denial.
Medium impact
Reinstatement of the HealthChoice Social Determinants of Health Workgroup
Maryland Medicaid·Effective Jan 1, 2027
Maryland Medicaid is reinstating the HealthChoice Social Determinants of Health Workgroup to develop a standardized, non-proprietary HRSN (Health-Related Social Needs) screening questionnaire to replace current proprietary instruments. This transition aims to reduce administrative burden, improve cost efficiency, and ensure consistent data collection across all HealthChoice MCOs. The new screening tool is targeted for implementation on January 1, 2027.
Medium impact
Updated Guidance on MCO Renewal Application Assistance and Outreach to Disenrolled Members
Maryland Medicaid·Effective Aug 1, 2026
Maryland MCOs now have expanded authority to assist Medicaid enrollees with renewal applications (effective August 1, 2026) and conduct outreach to members disenrolled for procedural reasons within 120 days. MCOs must ensure staff complete mandatory Maryland Health Benefits Exchange training, track assistance providers quarterly, and avoid any marketing or steering activities. This policy supersedes PT 76-25.
Medium impact
Disenrollment Process for HealthChoice Participants to Enroll in Program of All-Inclusive Care for the Elderly
Maryland Medicaid·Identified Sep 11, 2026
This policy establishes the disenrollment process for HealthChoice (Maryland Medicaid MCO) participants ages 55-64 who want to enroll in PACE (Program of All-Inclusive Care for the Elderly). Participants must complete voluntary disenrollment from their MCO via the OES 2000 form and cannot be enrolled in both simultaneously. PACE organizations must submit required documentation by the 20th of the month for disenrollment to be effective the last day of that month, with PACE enrollment beginning the first of the following month.
High impact
NCPDP Telecommunication Standard Version F6 Transition and Updated 340B Claim Identification
Maryland Medicaid·Effective Aug 14, 2027
Maryland Medicaid is transitioning to NCPDP Telecommunication Standard Version F6 for pharmacy transactions, with a phased implementation beginning August 14, 2027 (concurrent with Version D.0) and mandatory exclusive use by April 14, 2028. For 340B drug program claims, the identifier code is changing from Submission Clarification Code 20 (field 420-DK) to Submission Type Code AA (field D17-K8). Billing teams must update systems, coordinate with vendors, and prepare for impacts across claims processing, eligibility, and rebate reporting.
High impact
[Texas] Evolent Prior Authorization Updates Effective January 1, 2027 (PDF)
WellCare·Effective Jan 1, 2027
Effective January 1, 2027, Superior HealthPlan, Ambetter, and Wellcare will require prior authorization for 28 specific cardiac vascular revascularization procedures (CPT codes 37254, 37256, 37258, 37260, 37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37280, 37282, 37284, 37286, 37288, and others). Prior authorization requests must be submitted to Evolent Specialty Services, Inc. through their provider portal, phone, or fax. Exception: Medicaid members under 21 and Ambetter members under 18 are exempt from this requirement.
Medium impact
Remind Blue High-Performance Network® Members To See In-Network Providers
BCBS Oklahoma·Identified Sep 11, 2026
Blue Cross and Blue Shield of Oklahoma (BCBSOK) has issued a reminder that BlueHPN® (Blue High-Performance Network) is an EPO plan where members have coverage ONLY when using in-network providers, except in emergencies. Billing teams must verify member eligibility through Availity before rendering care and remind members to use in-network providers to avoid out-of-pocket costs. Claims should be filed using the same procedures as BlueCard® programs.
Low impact
[Ohio] Coming soon: new opportunities for MyCare Ohio long-term services and supports providers in 2027
Anthem BCBS·Identified Sep 11, 2026
Anthem Blue Cross and Blue Shield is announcing new value-based programs for MyCare Ohio long-term services and supports (LTSS) providers starting in 2027. Eligible providers will be contacted directly beginning in November 2026 with details about programs focused on care quality, member outcomes, provider partnerships, and network sustainability. Specific program details, eligibility criteria, and participation requirements will be communicated in future updates.
High impact
New Prior Authorization Requirement for Certain Procedures: Effective January 1, 2027
Ambetter·Effective Jan 1, 2027
Superior HealthPlan, Ambetter from Superior HealthPlan, Ambetter Health, and Wellcare By Superior HealthPlan Dual Align are adding prior authorization requirements for 18 vascular revascularization procedure codes (iliac, femoral, popliteal, tibial, and peroneal territories) effective January 1, 2027. Prior authorization requests must be submitted to Evolent Specialty Services, Inc. through their provider portal, phone, or fax. Age-based exemptions apply for Medicaid (STAR programs) members under 21 and Ambetter members under 18.
High impact
Update for Malnutrition CP.PP.145: Effective November 1, 2026
Ambetter·Effective Nov 1, 2026
Ambetter from Meridian is updating its Malnutrition policy (CP.PP.145) effective November 1, 2026, to include new criteria for both moderate (non-severe) and severe malnutrition diagnoses, along with two new ICD-10 codes (E44.0 and E44.1). The policy requires strict physician documentation to support malnutrition diagnoses billed as major complication/comorbidity (MCC) codes; claims lacking proper documentation will be denied.
Medium impact
Triptorelin (Triptodur®)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee is establishing a new medical policy for Triptorelin (Triptodur®) effective 12/1/26 that covers four indications: central precocious puberty (FDA-approved), gender dysphoria, ovarian function preservation, and acute porphyria prevention. The policy requires prior authorization with specific clinical documentation, age restrictions for gender dysphoria (subject to TN state law), and prescriber specialty requirements for gender dysphoria and porphyria cases.
High impact
Ipilimumab (Yervoy®)
BCBS Tennessee·Effective Dec 1, 2026
This is a comprehensive new medical policy for Ipilimumab (Yervoy®) that establishes coverage criteria for multiple cancer indications, including FDA-approved uses (melanoma, RCC, colorectal cancer, HCC, NSCLC, mesothelioma, esophageal cancer) and compendial uses across 30+ cancer types. The policy requires prior authorization with specific documentation of tumor molecular status (MSI-H, dMMR, POLE/POLD1, TMB-H, PD-L1 expression) and genetic testing results where applicable. Implementation is delayed until December 1, 2026.
Medium impact
Signature Requirements for Division of Developmental Disabilities Person-Centered Service Plans
Missouri Medicaid (MO HealthNet)·Effective Sep 10, 2026
Effective immediately, all Missouri Medicaid Division of Developmental Disabilities Person-Centered Service Plans (PCSPs) require signature approval by the individual and/or legally responsible person before implementation. Signatures may be handwritten or electronic, with electronic signatures subject to 13 CSR 65-3.050 compliance standards. This applies to all initial, annual, and amended PCSPs with no exceptions.
Medium impact
New 2026 model of care training available
Harvard Pilgrim Health Care·Identified Sep 11, 2026
Tufts Health Plan SCO (Senior Care Options) is requiring all participating PCPs and specialists to complete an updated 2026 Model of Care training by December 31, 2026. This is a CMS-mandated annual requirement covering plan goals, care coordination, transition of care, and performance measures. Completion requires attestation on the Point32Health provider website.
Medium impact
Leqvio® (inclisiran) (Revised)
Humana·Effective Jan 1, 2026
Humana has revised its Leqvio (inclisiran) prior authorization policy effective January 1, 2026, with an update dated August 26, 2026. The policy now covers this PCSK9 inhibitor for hypercholesterolemia and familial hypercholesterolemia in specific patient populations (age 18+ for general hypercholesterolemia; age 12+ for HeFH and pediatric HoFH), requiring documented statin failure or statin-associated muscle symptoms, and step therapy with Repatha for MAPD and SC Medicaid plans. Billing teams must implement prior authorization requirements and verify step therapy compliance before claim submission.
Medium impact
Transcatheter Valve Procedures - Medicare Advantage (Revised)
Humana·Effective Sep 10, 2026
This is a revised Medicare Advantage coverage policy for transcatheter valve procedures (TAVR, TEER, TTVR, and related interventions) effective September 10, 2026. The policy establishes coverage criteria, references applicable CMS National Coverage Determinations, and outlines covered device types across all four cardiac valves. Billing teams must ensure claims align with the specific FDA-approved devices and clinical indications detailed in this policy.
High impact
Molecular Markers in Fine Needle Aspirates of Thyroid Nodules - Medicare Advantage (Revised)
Humana·Effective Sep 10, 2026
This revised Medicare Advantage policy (effective 09/10/2026) establishes coverage criteria for molecular marker testing in fine needle aspirates of thyroid nodules, including Afirma GSC, ThyGeNext/ThyraMIRv2, and ThyroSeq v3 GC tests. Coverage is determined by applicable MAC Local Coverage Determinations (LCDs) in each jurisdiction, with specific criteria varying by geographic region and test type.
High impact
Register for Webinar on Coding for Evaluation and Management Claims
BCBS Illinois·Effective Jul 1, 2026
Effective July 1, 2026, Blue Cross Blue Shield refined their claims editing and review process for office, inpatient, and outpatient evaluation and management (E/M) services for commercial members. A mandatory webinar is being offered to educate providers on these changes to ensure accurate billing and proper reimbursement.
Medium impact
Remind Blue High Performance Network® Members To See In-Network Providers
BCBS Illinois·Identified Sep 11, 2026
This policy reminds providers that Blue High Performance Network (BlueHPN) members have coverage ONLY when seeing in-network BlueHPN providers, except in emergencies. Providers should verify member eligibility via Availity before rendering care and remind members to use in-network providers to avoid out-of-pocket costs. Claims should be submitted following standard BlueCard procedures.

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Archive by year

2023 2024 2025 2026

26-1042 Route Covered DME and Home Respiratory Services Referrals to Apria

26-1061sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk

26-1062sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk

26-1060sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk

Updated Preventive Coverage for Colorectal Cancer Screening to add SimpleScreen™ CRC for Medicare Advantage Members (Effective July 24, 2026)

Referral Coordination for Certain Institutional Settings for Medical Day Care Services Waiver

Medicare Enrollment Requirement for High Risk-Provider Types

Reinstatement of the HealthChoice Social Determinants of Health Workgroup

Updated Guidance on MCO Renewal Application Assistance and Outreach to Disenrolled Members

Disenrollment Process for HealthChoice Participants to Enroll in Program of All-Inclusive Care for the Elderly

NCPDP Telecommunication Standard Version F6 Transition and Updated 340B Claim Identification

[Texas] Evolent Prior Authorization Updates Effective January 1, 2027 (PDF)

Remind Blue High-Performance Network® Members To See In-Network Providers

[Ohio] Coming soon: new opportunities for MyCare Ohio long-term services and supports providers in 2027

New Prior Authorization Requirement for Certain Procedures: Effective January 1, 2027

Update for Malnutrition CP.PP.145: Effective November 1, 2026

Triptorelin (Triptodur®)

Ipilimumab (Yervoy®)

Signature Requirements for Division of Developmental Disabilities Person-Centered Service Plans

New 2026 model of care training available

Leqvio® (inclisiran) (Revised)

Transcatheter Valve Procedures - Medicare Advantage (Revised)

Molecular Markers in Fine Needle Aspirates of Thyroid Nodules - Medicare Advantage (Revised)

Register for Webinar on Coding for Evaluation and Management Claims

Remind Blue High Performance Network® Members To See In-Network Providers