High impact
New and Updated Clinical Payment Policies: December 20th, 2026 (PDF)
Ambetter·Effective Dec 20, 2026
Home State Health Plan implemented seven clinical payment policy changes effective December 20, 2026, affecting behavioral health documentation requirements, burn surgery coverage, fetal surgery criteria, epidural injection frequency limits, therapy services language requirements, genetic testing, and gender-affirming procedures. The most operationally significant change is the Behavioral Health Treatment Documentation Requirements policy (HIM.CP.BH.500/CP.MP.500), which adds nine new documentation elements and modifies existing requirements for mental health claims. Billing teams must immediately review affected policies, update documentation templates and prior authorization workflows, and communicate requirements to providers.