Provider News - July 2026

REQUIREMENTS: Immediately (July 1, 2026): Billing team must transition all pharmacy prior authorization (PA) submissions to online CoverMyMeds.com platform for all lines of business (commercial, exchange, Medicare Advantage, Medicaid). Update internal workflows to eliminate fax/phone PA submission methods. Staff must be trained on CoverMyMeds portal access and tracking procedures. Failure to submit PAs through new channel may delay coverage decisions at pharmacy. By January 1, 2027: (1) Billing team must update all maternity care billing procedures to transition from global maternity care codes to itemized billing structure. Audit and update billing software to prevent use of global maternity codes. Providers must update documentation and coding templates. (2) All clinical staff must transition to using revised DMS-1000 form (previously F-01164) for all sterilization procedure authorizations and claims. Remove old F-01164 forms from all locations and systems. Obtain and distribute new DMS-1000 forms to providers. Before January 1, 2027: (1) Billing team must identify all patients with SSI Medicaid coverage and initiate member communication regarding plan discontinuation and transition requirements. Coordinate with clinical staff on coverage gap prevention. (2) Providers and clinical documentation staff must implement cancer diagnosis documentation requirements: ensure all cancer diagnoses are documented as either active or historical status based on clinical criteria. Update EMR templates and provider order sets to include status clarification. Active cancer diagnoses impact risk adjustment coefficients; historical cancer diagnoses do not. Ongoing: Providers must document accurate ICD-10-CM diagnosis codes with active/historical status for all cancer diagnoses to ensure correct risk scoring.