By June 1, 2025: Billing team must access MVP Health Care's Provider FastFax Library and detailed Medical Policies to obtain specific billing code requirements, prior authorization rules, and coverage determinations for all 24 affected policy areas. For each affected service line (cardiac monitoring, ACI/OATS procedures, BPH treatments, orthotic/prosthetic devices, scoliosis surgery, sleep apnea surgery, etc.), update billing software with new prior auth requirements, coverage limitations, and coding guidelines. Communicate changes to clinical staff and update encounter forms/templates. Establish internal deadline to complete implementation by June 15, 2025. Claims submitted without updated coding, documentation, or required prior authorizations after June 1, 2025, will be denied. Do NOT process claims under old policy parameters after the effective date.

Effective immediately (7/17/2026): Billing team must implement verification protocols to ensure all Zepbound claims for OSA diagnosis include attached sleep study documentation meeting AASM guidelines with AHI ≥15 events/hour before submission. Update claim submission checklist in billing system to flag missing sleep study records. Providers must verify patient BMI ≥30 kg/m² is documented in the medical record. Establish internal audit process to review Zepbound claims before transmission to Alaska Medicaid. Educate all clinical staff that Zepbound prescribed for weight management only (without qualifying OSA diagnosis and sleep study) will be denied and subject to recoupment. Implement denial management protocol for claims rejected due to missing or non-qualifying sleep study documentation.

By June 30, 2026: Billing team must implement the following workflow changes: (1) Update billing software to flag and deny all related ancillary services, medications, and procedures when a primary service is denied for lack of prior authorization, untimely authorization, or failure to meet medical necessity criteria; (2) Configure system to deny claims billed on separate claim forms that are linked to a denied primary service; (3) Ensure exceptions are programmed for ambulance services and radiology/pathology report readings; (4) For Maine-contracted providers: maintain current medical necessity review process per Maine statute 24-A MRS §4304 and do NOT apply the cascading denial logic to fully insured Maine members; (5) Audit all pending claims with ancillary services to identify potential cascading denials under the new rules; (6) Train providers and billing staff on the new denial cascade logic and the importance of obtaining prior authorization BEFORE billing any related services. Failure to implement these changes will result in improper claim processing and potential revenue impact from related service denials.

By August 3, 2026: (1) Billing and clinical staff must update e-prescribing systems to route all specialty and complex care medication prescriptions to Free Market Health Pharmacy (NPI: 1366292880) instead of traditional network pharmacies. (2) Providers must continue submitting prior authorization requests to Blue Cross and Blue Shield of Illinois through existing channels when required for pharmacy benefits. (3) Update internal workflows to expect referral confirmation faxes from Free Market Health and be prepared for contact from matched specialty pharmacies. (4) Ensure front desk and clinical staff are aware that new specialty pharmacies may contact the practice as part of the matching and onboarding process. (5) Maintain contact information for Free Market Health (412-755-3241, email, 833-998-4435 fax, 877-787-0520) for questions. This change applies only to fully insured commercial plans on BCBSIL and does not affect Medicare or Medicaid members. Failure to route prescriptions through the new process may result in claim denials or delays in member access to specialty medications.