HCPCS G2074 is officially defined as "Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program)." HCPCS G2074 is referenced in 8 tracked payer policy changes from Sentara Health Plans, Ambetter, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS G2074 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
This historical notice, dated 07/17/26, is Ambetter's reimbursement update for the Texas Health Insurance Marketplace and ICHRA health insurance and HMO plans. It states that definitive drug testing CPT codes 80320-80377 will no longer be reimbursable effective October 1, 2026, and that providers should bill G0480 or G0481 for definitive drug testing. It also states that claims will be denied effective 10/01/2026 for specified MH/SUD testing and treatment code pairs billed for the same member and provider within 7 calendar days, and that clinical payment policy TX.CP.MP.50-A, on definitive testing for more than 14 drugs or drug classes, takes effect September 1, 2026.
Health Net is implementing new claims editing requirements effective June 30, 2026, that will automatically deny claims using incorrect new vs. established patient codes and component codes that should be bundled with comprehensive procedures. The policy particularly affects mental health providers with specific drug testing code bundling rules using a 7-day lookback period.
Aetna is implementing multiple policy changes effective April 1, 2026, including new prior authorization requirements for specialty drugs and procedures, bundling of medication-assisted treatment services, updated coding rules for ventral hernias, and new modifier requirements for reduced/discontinued services.
Aetna has updated its Medication-Assisted Treatment (MAT) policy for opioid use disorder (CPB 1104), establishing comprehensive medical necessity criteria and program requirements. This policy defines strict documentation standards, qualified provider mandates, SAMHSA certification requirements, and mandatory clinical assessments (including urine toxicology, psychiatric evaluation, and annual physicals) for all MAT treatment. Billing teams must ensure claims include proper bundled HCPCS codes (G2067-G2075) and supporting clinical documentation meeting these new standards.
Kansas Medicaid (KMAP) has updated reimbursement rates for Opioid Use Disorder treatment codes effective January 1, 2026. The bulletin provides specific payment amounts for 17 different HCPCS codes used for OUD services, with rates ranging from $16.50 to $1,979.58.
Aetna's CPB 1104 establishes comprehensive medical necessity criteria for medication-assisted treatment (MAT) for opioid use disorder, requiring specific program certifications, provider qualifications, clinical documentation standards, and ongoing assessments. This policy defines covered HCPCS bundled codes (G2067–G2075) and related drug testing CPT codes for MAT delivery through licensed opioid treatment programs (OTPs).
Aetna considers presumptive urine drug testing medically necessary for people in a chronic pain or substance use disorder program when an indication applies, such as starting treatment in the program, suspected illegal or non-prescribed substance use, suspected overdose, monitoring of chronic opioid therapy, or testing documented as part of an active treatment plan. Definitive or confirmatory urine testing is medically necessary only for people who meet the presumptive testing criteria and also have a listed indication, such as no commercially available presumptive test, an inconclusive or inconsistent presumptive result, or a disputed presumptive result. Testing ordered by courts, schools, employers or other third parties is considered not medically necessary.
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