[Virginia] August 2026 Provider Newsletter

REQUIREMENTS: Before September 1, 2026: Billing team must review and implement the following changes: - Review CMS observation service billing requirements before September 1, 2026 (affects Medicare Advantage claims). Update billing protocols and provider education materials on observation vs. inpatient designation. - Update telehealth claims processing for ICD-10-CM Excludes1 editing effective September 1, 2026 (affects Medicare Advantage and Medicaid). Validate that billing system correctly applies Excludes1 rules to telehealth encounter coding. - Review NDC edit requirements for Medicare Advantage claims effective August 1, 2026 (immediate). Ensure billing system applies National Drug Code edits to all pharmacy claims. Before October 1, 2026: Billing team must transition to electronic claims and payment processing: - Implement no-cost electronic claims submission and electronic payments to avoid paper administrative fees effective October 1, 2026 (affects Medicare Advantage). Update all billing workflows to use electronic submission; paper claims will incur administrative fees. Before November 1, 2026: Prior Authorization and Coverage Updates: - Update prior authorization requirements effective November 1, 2026. New precertification list changes for Commercial and Medicare Advantage plans require prior auth review. Billing team must update system with expanded precertification requirements from Carelon Medical Benefits Management (Commercial and Medicare Advantage). - Update coverage guidelines effective November 1, 2026 (Commercial). Ensure system reflects new prior authorization requirements for all affected service lines. - Update Specialty Pharmacy precertification list effective November 1, 2026 (Medicare Advantage). Add all newly precertified specialty pharmacy services to authorization workflow. Before December 1, 2026: Additional Prior Authorization Changes: - Update VA precertification/prior authorization list effective December 1, 2026 (Commercial). Import updated list into authorization system. - Update precertification/prior authorization list effective December 1, 2026 (Commercial). Communicate list changes to provider network and front desk staff. Immediate Actions: - Providers should review flu prevention and immunization measures webinar materials (all plan types). - Notify providers of ComplexCare Solutions SOAP note incentive program ending August 31, 2026 (Commercial). Stop incentive payments after this date. - Ensure billing team completes access survey participation for primary care, specialty care, and behavioral health practitioners (Commercial). Consequences of inaction: Claims may be denied for failure to obtain required prior authorization, NDC edits may cause claim rejections, observation service claims may be improperly coded and denied, and paper claims will incur administrative fees.