Reminder: Changes Coming in 2026

By December 31, 2025: (1) Billing and authorization teams must review Medical Policy Z-109 (Commercial) and Z-129 (Medicare Advantage) for your state to understand new site of care clinical review requirements and documentation thresholds for outpatient surgeries. (2) Update prior authorization workflows to process written clinical justifications and member provider continuity requests per the new policy exclusions. (3) Identify which outpatient surgical procedures will be subject to site of care review and ensure providers document clinical justification when hospital-based settings are medically necessary. (4) For New York providers: Prepare for claims and payment processing changes effective January 26, 2026 when ECHO Health assumes management of 835 remittances and 837 claims processing for Western and Northeastern New York regions—contact Highmark for transition details and timeline. (5) Update billing software to recognize new CopayGo tiered network structure for applicable ASO large group accounts. (6) Communicate with all network providers about Medicare Advantage network changes and ensure scheduling systems reflect any in-network/out-of-network status changes. Failure to comply with site of care clinical review requirements may result in authorization denials or claim rejections.