All Insurance Policy Changes (Page 80)

Continuing from page 79. 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
Louisiana Medicaid Pharmacy – Tropical Storm Bertha Preparation – July 2026
Louisiana Medicaid·Effective Jul 20, 2026
Louisiana Medicaid is temporarily waiving early refill edits and automatically extending all prior authorizations for non-controlled pharmacy claims through July 28, 2026, to help beneficiaries maintain medication access during Tropical Storm Bertha. These emergency flexibilities apply to both Fee-for-Service and Managed Care Organization claims but explicitly exclude controlled substances.
Medium impact
Authorization Updates - Effective July 1, 2026
Sentara Health Plans·Effective Jul 1, 2026
Effective July 1, 2026, Sentara Health Plans is removing prior authorization requirements for CPT 75577 (cardiac plaque assessment) for all Virginia Commercial products, and expanding the RSV vaccine (90678) exception to include pregnant individuals at 32-36 weeks gestation across Virginia Medicaid and Commercial plans. Affected claims will be automatically reprocessed.
Medium impact
Authorization Updates - Effective November 1, 2026
Sentara Health Plans·Effective Nov 1, 2026
Effective November 1, 2026, Sentara Health Plans will require prior authorization/precertification for buprenorphine implant (J0570, 74.2mg) for all Medicaid products in Virginia. Billing teams must obtain authorization before submitting claims for this code to avoid denials.
Medium impact
Drug Policy Criteria Change
Arkansas Blue Cross Blue Shield·Effective Aug 10, 2026
This policy updates coverage criteria for two specialty drugs: Fabhalta now requires a lower urine protein-to-creatinine ratio (UPCR) threshold of 0.5 g/g for IgAN patients (down from 0.8 g/g) with expanded continuation criteria, and Hympavzi coverage is extended to pediatric patients ages 6+ (removing the 35 kg weight requirement). Both changes are effective 8/10/2026.
High impact
Policy Criteria Change
Arkansas Blue Cross Blue Shield·Effective Sep 24, 2026
Arkansas Blue Cross updated authorization renewal criteria for 8 oncology and specialty pharmaceutical drugs, effective September 24, 2026. Changes simplify renewal requirements to focus on disease stability/improvement, manageable side effects, and specific treatment parameters (e.g., no therapeutic duplication for Panitumumab, 24-month treatment limit for Retifanlimab-dlwr). Additionally, the legacy Chemotherapy for Malignancy policy (2000030) will be archived on October 24, 2026, with replacement coverage under new policy 2026011.
Medium impact
[California] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross Medicare Advantage plans in California will require precertification/prior authorization for CPT 93356 (myocardial strain imaging using speckle tracking). Billing teams must implement prior auth requirements in their systems and encounter workflows for this cardiac imaging code to avoid claim denials.
Medium impact
[California] Prior authorizations for genetic testing care services
Anthem BCBS·Effective Jul 1, 2026
Effective July 1, 2026, Anthem Blue Cross is consolidating prior authorization for genetic testing services (specifically pre-implantation embryo genetic testing) under Carelon Medical Benefits Management for Commercial groups that selected this program. Providers must now submit all genetic testing prior authorization requests exclusively to Carelon Medical Benefits Management instead of Anthem Blue Cross, streamlining the review process through a single entity.
High impact
[California] Telehealth claims update: ICD-10-CM Excludes1 editing
Anthem BCBS·Effective Sep 1, 2026
Beginning September 1, 2026, Anthem Blue Cross will apply ICD-10-CM Excludes1 editing rules to telehealth claims billed with Place of Service (POS) 02 or POS 10, matching the standards already applied to other claim types. Telehealth claims with diagnosis code combinations prohibited by Excludes1 notes may be denied for reimbursement. Providers must verify diagnosis code combinations comply with Excludes1 conventions before submitting telehealth claims.
Medium impact
[New York] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Medicare Advantage plans in Indiana and New York will require prior authorization for CPT 93356 (myocardial strain imaging using speckle tracking). Billing teams must obtain precertification before performing this service or claims will be denied as ineligible for payment.
Medium impact
[New York] Prior authorizations for genetic testing care services
Anthem BCBS·Effective Jul 1, 2026
Effective July 1, 2026, Anthem Blue Cross and Blue Shield is consolidating prior authorization for genetic testing services (specifically pre-implantation embryo genetic testing) under Carelon Medical Benefits Management for participating New York groups. Providers must submit all genetic testing prior authorization requests exclusively to Carelon Medical Benefits Management instead of to Anthem directly. This streamlines the review process through a single entity.
High impact
[New York] Telehealth claims update: ICD-10-CM Excludes1 editing
Anthem BCBS·Effective Sep 1, 2026
Beginning September 1, 2026, telehealth claims billed with Place of Service (POS) 02 or POS 10 will be subject to ICD-10-CM Excludes1 editing rules, the same as in-person claims. Claims submitted with diagnosis code combinations prohibited by Excludes1 notes may be denied for reimbursement. Providers must verify diagnosis codes do not violate Excludes1 conventions before submitting telehealth claims.
Low impact
[New York] Partnering with Circadian Health, Inc. to help manage patients with chronic conditions
Anthem BCBS·Effective Jul 20, 2026
Anthem is announcing a new partnership with Circadian Health, Inc., a virtual specialty care provider for managing chronic conditions (heart failure, hypertension, COPD, diabetes) in New York. This is an educational bulletin informing providers about a new referral pathway and care coordination option; it does not impose new billing requirements, prior authorization mandates, or coverage changes at this time.
Medium impact
[Ohio] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross and Blue Shield will require prior authorization for CPT code 93356 (myocardial strain imaging using speckle tracking) for all Medicare Advantage and Fully Integrated Dual Eligible (FIDE) plans in Ohio. Services performed without prior authorization may be denied for payment.
Medium impact
[Ohio] Prior authorizations for genetic testing care services
Anthem BCBS·Effective Jul 1, 2026
Effective July 1, 2026, Anthem Blue Cross and Blue Shield in Ohio is consolidating prior authorization for genetic testing services (specifically pre-implantation embryo genetic testing) under Carelon Medical Benefits Management. Providers must submit all genetic testing reviews exclusively to Carelon instead of Anthem, streamlining the review process into a single entity.
High impact
[Ohio] Telehealth claims update: ICD-10-CM Excludes1 editing
Anthem BCBS·Effective Sep 1, 2026
Beginning September 1, 2026, Anthem will apply ICD-10-CM Excludes1 editing rules to telehealth claims billed with POS 02 or POS 10, matching standards already applied to in-person claims. Claims with prohibited diagnosis code combinations per Excludes1 notes may be denied for reimbursement. Providers must verify diagnosis codes comply with Excludes1 conventions before submission.
Medium impact
[Virginia] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross and Blue Shield will require prior authorization for CPT code 93356 (myocardial strain imaging using speckle tracking) for all Medicare Advantage members in Virginia, including FIDE, ISNP, and CSNP plans. Claims submitted without prior authorization may be denied.
Medium impact
[Virginia] Prior authorizations for genetic testing care services
Anthem BCBS·Effective Jul 1, 2026
Effective July 1, 2026, Anthem Blue Cross and Blue Shield in Virginia is consolidating all prior authorization reviews for genetic testing services (specifically pre-implantation embryo genetic testing) exclusively to Carelon Medical Benefits Management. Providers must submit all genetic testing prior authorization requests to Carelon instead of Anthem, streamlining the review process through a single entity.
High impact
[Virginia] Telehealth claims update: ICD-10-CM Excludes1 editing
Anthem BCBS·Effective Sep 1, 2026
Beginning September 1, 2026, Anthem Blue Cross Blue Shield and HealthKeepers will enforce ICD-10-CM Excludes1 editing rules on telehealth claims (POS 02 and POS 10) to match requirements applied to other claim types. Claims with diagnosis code combinations prohibited by Excludes1 notes may be denied for reimbursement. Providers must verify diagnosis codes comply with Excludes1 conventions before submission.
Medium impact
[Georgia] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross Blue Shield Medicare Advantage plans in Georgia will require prior authorization for CPT code 93356 (myocardial strain imaging using speckle tracking). Providers must obtain precertification before billing this service or claims will be denied as ineligible for payment.
Medium impact
[Georgia] Prior authorizations for genetic testing care services
Anthem BCBS·Effective Jul 1, 2026
Effective July 1, 2026, Anthem Blue Cross and Blue Shield in Georgia is consolidating prior authorization for genetic testing services (specifically pre-implantation embryo genetic testing) under Carelon Medical Benefits Management for groups enrolled in their genetic testing program. Providers must now submit all genetic testing prior authorization requests exclusively to Carelon Medical Benefits Management instead of Anthem directly.
High impact
July 2026 billing policy updates
Priority Health·Effective Jul 23, 2026
Priority Health published 15 billing policy updates effective July 23 and September 23, 2026, affecting multiple service lines including OMT, DME, oncology, sleep medicine, and vascular studies. Key changes include clarifications on modifier usage, supply limit calculations, coding guidelines, and medical necessity criteria. Billing teams must review and implement updates across multiple service categories to ensure accurate claim submission.
Medium impact
Reminder: HIDE-SNP members may qualify for Long-Term Services and Support
Priority Health·Identified Jul 21, 2026
Priority Health is reminding providers that HIDE-SNP (Highly Integrated Dual Eligible Special Needs Plan) members may qualify for Long-Term Services and Supports (LTSS) through Carallel, including assistance with daily activities, household support, and nursing facility care. Providers should refer eligible members directly to their Care Manager or call the customer service line at 833.939.0983 to initiate LTSS referrals.
Low impact
Register to Attend Florida Blue’s August Quality Innovations Webinar
Florida Blue·Effective Aug 25, 2026
Florida Blue is hosting a complimentary educational webinar on August 25, 2026, focused on behavioral health HEDIS measures and quality improvement strategies. This is an informational announcement about a continuing education opportunity with AAFP credit eligibility, not a billing or coverage policy change.
Medium impact
SFY 2025 Financial Compliance Report Now Open in STEPS
Texas Medicaid·Effective Jul 20, 2026
HHSC has launched STEPS, a new web-based system for Medicaid financial compliance reporting in Texas. The SFY 2025 Financial Compliance Report (FCR) collection opens July 20, 2026, with a due date of September 18, 2026. Completion is voluntary for most providers, but all primary contacts, financial contacts, and cost report preparers must complete mandatory web-based training before accessing the system.
Low impact
HHSC to Host July 29 Defining the MDS: Webinar with HHSC LTCR
Texas Medicaid·Effective Jul 29, 2026
HHSC Long-Term Care Regulation is hosting a free educational webinar on July 29, 2026 to train Resident Assessment Instrument (RAI) coordinators and staff on Minimum Data Set (MDS) coding accuracy. The webinar covers RAI process anatomy, MDS question types, and accurate coding for quality care, reimbursement, and survey compliance. This is an optional educational opportunity, not a policy mandate.

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Insurance Policy Changes Tracker: All Payer Updates (Page 80) | PolicyChanges.app

Louisiana Medicaid Pharmacy – Tropical Storm Bertha Preparation – July 2026

Authorization Updates - Effective July 1, 2026

Authorization Updates - Effective November 1, 2026

Drug Policy Criteria Change

Policy Criteria Change

[California] Precertification/prior authorization requirement changes

[California] Prior authorizations for genetic testing care services

[California] Telehealth claims update: ICD-10-CM Excludes1 editing

[New York] Precertification/prior authorization requirement changes

[New York] Prior authorizations for genetic testing care services

[New York] Telehealth claims update: ICD-10-CM Excludes1 editing

[New York] Partnering with Circadian Health, Inc. to help manage patients with chronic conditions

[Ohio] Precertification/prior authorization requirement changes

[Ohio] Prior authorizations for genetic testing care services

[Ohio] Telehealth claims update: ICD-10-CM Excludes1 editing

[Virginia] Precertification/prior authorization requirement changes

[Virginia] Prior authorizations for genetic testing care services

[Virginia] Telehealth claims update: ICD-10-CM Excludes1 editing

[Georgia] Precertification/prior authorization requirement changes

[Georgia] Prior authorizations for genetic testing care services

July 2026 billing policy updates

Reminder: HIDE-SNP members may qualify for Long-Term Services and Support

Register to Attend Florida Blue’s August Quality Innovations Webinar

SFY 2025 Financial Compliance Report Now Open in STEPS

HHSC to Host July 29 Defining the MDS: Webinar with HHSC LTCR