What insurance policy changes affect CPT 98960?

There are 12 tracked policy changes affecting CPT 98960, including updates from Blue Cross Blue Shield of Rhode Island, Harvard Pilgrim Health Care, Nevada Medicaid. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

How do I get notified when CPT 98960 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 98960. You will receive a daily digest email whenever a new policy change references this code.

Why do payers change policies for CPT 98960?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

98960 Insurance Policy Changes

Q: Which payers have updated policy for CPT 98960?

Payers that have issued tracked updates for CPT 98960 include: Blue Cross Blue Shield of Rhode Island, Harvard Pilgrim Health Care, Nevada Medicaid, New Mexico Medicaid, EmblemHealth, Florida Blue, Medi-Cal.

CPT 98960 is referenced in 12 tracked payer policy changes from Blue Cross Blue Shield of Rhode Island, Harvard Pilgrim Health Care, and 5 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 98960 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

High impact
Payment policy updates
Blue Cross Blue Shield of Rhode Island·Effective Jan 1, 2026
BCBSRI has implemented multiple policy changes affecting preventive services, coding, and reimbursement across various specialties. Key changes include new breast cancer screening coverage requirements, updated STI testing billing procedures, hearing aid coverage increases, and several new CPT/HCPCS codes for various services.
High impact
Update: Telehealth flexibilities for Medicare members
Harvard Pilgrim Health Care·Effective Oct 1, 2025
Point32Health will continue telehealth coverage for Medicare Advantage members as supplemental benefits effective October 1, 2025, regardless of CMS decisions. Specific codes across multiple specialties including cardiac rehab, mental health, physical therapy, and pulmonary rehab will remain eligible for telehealth reimbursement.
High impact
Payment policy updates
Blue Cross Blue Shield of Rhode Island·Effective Oct 1, 2025
Multiple policy updates affecting various services including COVID-19 treatments, bundled services, preventive care, and Medicare Advantage acupuncture coverage. Key changes include CPT code corrections for monoclonal antibodies, new bundling restrictions effective October 2025, and elimination of most acupuncture coverage for Medicare Advantage in 2026.
High impact
Updates to Limitation Error Codes
Nevada Medicaid·Effective Apr 28, 2025
Nevada Medicaid has implemented new service limitation error codes and prior authorization requirements for multiple procedure codes effective April 28, 2025. Key changes include new unit limits for allergy testing and therapy codes, prior auth requirements for psychological testing, and restrictions on who can bill certain codes.
Medium impact
Payment Policies
Blue Cross Blue Shield of Rhode Island·Effective Sep 1, 2025
BCBSRI now requires lactation consultation services to be billed with the mother as the patient, not the infant. Claims submitted under infants (ages 0-12 months) will be denied, and only one unit of CPT 98960 per date of service will be reimbursed.
Medium impact
Supplement 25-10: Implementation of Community Health Worker (CHW) and Community Health Representatives (CHR) Updates Per Repeal and Replace Letter of Direction
New Mexico Medicaid·Effective Aug 25, 2025
New Mexico Medicaid now covers Community Health Worker (CHW) and Community Health Representative (CHR) services starting August 25, 2025. CHWs/CHRs must enroll as Provider Type 462/Specialty 230, obtain DOH certification, and can bill CPT codes 98960-98962 for patient education services with physician orders or standing orders.
Medium impact
Chronic Disease Self-Management Program for Medicaid and HARP
EmblemHealth·Effective Jun 1, 2025
EmblemHealth will begin covering the Chronic Disease Self-Management Program (CDSMP) for Medicaid and HARP members age 18+ with arthritis diagnoses starting June 1, 2025, using CPT code 98960. This is a new covered benefit for evidence-based group and individual chronic disease management services.
Medium impact
Attention Provider Type 17 (Special Clinics) Specialty 174 (Public Health Clinic): Update Regarding Claims for Education and Training
Nevada Medicaid·Effective May 19, 2025
Nevada Medicaid now allows Public Health Clinics (Provider Type 17, Specialty 174) to submit claims for patient education and training codes 98960-98962 without automatic suspension, effective May 19, 2025. Previously suspended claims dating back to June 2022 have been released for reprocessing.
Medium impact
Attention Provider Type 60 (School Health Services): Modifier GN is No Longer Required on Claims for Procedure Codes 98960, 98961, and 98962
Nevada Medicaid·Effective Apr 7, 2025
Nevada Medicaid has eliminated the requirement for modifier GN on CPT codes 98960, 98961, and 98962 when billed by School Health Services providers (type 60). This change allows non-speech language pathologists to bill these patient education codes without the outpatient speech language service modifier.
Medium impact
Attention Provider Type 89 (Community Healthcare Workers): Update to Error Codes for Service Limitations
Nevada Medicaid·Effective Feb 18, 2025
Nevada Medicaid updated error codes for Community Healthcare Workers (Provider Type 89) effective February 18, 2025. CHWs can now submit prior authorization requests to exceed daily and monthly service limits for patient education codes 98960-98962, with new PA override error codes replacing automatic denials.
Medium impact
Improve Behavioral Health Outcomes with Accurate Reporting
Florida Blue·Identified Jun 16, 2026
Florida Blue updated guidelines for behavioral health HEDIS reporting, emphasizing accurate documentation and coding for mental health and substance use disorder treatments. The policy highlights specific CPT codes 98960-98962 and HCPCS code G0155 for behavioral health screenings and follow-up visits to improve quality scores and patient outcomes.
Medium impact
Coming Soon: Important Policy Reminders and Clarifications for Covered Medi-Cal CHW Services
Medi-Cal·Identified May 3, 2026
California DHCS is updating the Medi-Cal Provider Manual to clarify billing requirements for Community Health Worker (CHW) preventive services, including individual and group billing procedures using specific CPT and HCPCS codes, and telehealth usage guidelines.

All billing codes J3590 99212 99213 99202 99211 99214

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Payment policy updates

Update: Telehealth flexibilities for Medicare members

Payment policy updates

Updates to Limitation Error Codes

Payment Policies

Supplement 25-10: Implementation of Community Health Worker (CHW) and Community Health Representatives (CHR) Updates Per Repeal and Replace Letter of Direction

Chronic Disease Self-Management Program for Medicaid and HARP

Attention Provider Type 17 (Special Clinics) Specialty 174 (Public Health Clinic): Update Regarding Claims for Education and Training

Attention Provider Type 60 (School Health Services): Modifier GN is No Longer Required on Claims for Procedure Codes 98960, 98961, and 98962

Attention Provider Type 89 (Community Healthcare Workers): Update to Error Codes for Service Limitations

Improve Behavioral Health Outcomes with Accurate Reporting

Coming Soon: Important Policy Reminders and Clarifications for Covered Medi-Cal CHW Services