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ExchangeCoverageMedium impact

[Ohio] Avalon Policy Updates Q3/Q4 2025

CareSource·OH, GA · Internal Medicine, Family Medicine, OB-GYN +10 more·Medical Policy
Effective date
Jun 1, 2026
We identified it
May 9, 2026
Days to comply

Summary

CareSource/Avalon is updating 36 laboratory benefit management policies across Ohio and Georgia marketplace and D-SNP plans, effective June 1, 2026. These policies govern routine testing management (RTM) and post-service pre-payment clinical claim editing for laboratory services. Billing teams must verify specific policy details on Avalon's website to understand coverage criteria and documentation requirements for affected lab tests.

Action Required

Action needed
By May 15, 2026: Billing team must access Avalon Healthcare Solutions website and review the full policy text for all 36 updated G-series and M-series laboratory policies (G2002, G2006, G2007, G2011, G2035, G2036, G2043, G2048, G2050, G2051, G2059, G2060, G2063, G2100, G2105, G2110, G2113, G2115, G2119, G2121, G2123, G2124, G2149, G2150, G2151, G2153, G2154, G2155, G2156, G2158, G2159, G2173, G2174, M2057, M2068, M2097, M2116). Document any changes to medical necessity criteria, frequency limits, or coverage restrictions. Update billing software and coding guidelines in the EHR to reflect new requirements for Ohio Marketplace, Georgia Marketplace, and Georgia D-SNP members. Notify laboratory and ordering providers of coverage changes. Failure to apply updated policies may result in post-service claim denials and recoupment.