OfficeLink Updates - September 2026 newsletter

REQUIREMENTS: By November 15, 2026: Billing team must prepare for new claim edits from the Claim and Code Review Program (CCRP) effective December 1, 2026. Review the provider portal on Availity to identify all new claim edits that will be applied to commercial, Medicare, and Student Health member claims. Update internal billing policies and staff training documentation to reflect these edits to prevent claim denials. Before January 1, 2027: Billing team and clinical staff must transition maternity care coding to the new AMA/ACOG service-based framework (away from global maternity billing model). Update billing software rules, encounter templates, and provider documentation requirements to support detailed service-based coding for maternity services. This is a mandatory industry-wide change affecting all maternity claims. Before January 1, 2027: Pharmacy team must identify in-network pharmacy changes effective January 1, 2027. If your practice refers patients to any pharmacy leaving the network or has been using out-of-network pharmacies, identify replacement in-network pharmacies immediately. Update patient referral lists and communicate changes to clinical staff to prevent patient access issues and potential claim denials. Immediately: All providers must verify and update profile information in the Provider Data Management (PDM) tool on Availity. Outdated information could result in removal from the Aetna provider directory and failure to receive critical updates. Medicare providers must also update information in the National Plan and Provider Enumeration System (NPPES) to ensure accurate display in Medicare Plan Finder. Immediately: Credentialing departments must ensure current credentialing department email addresses are registered with Aetna to receive future policy updates and communications. As soon as possible: Evaluate digital prior authorization (PA) integration into your EHR workflow. Begin planning transition from manual PA processes to digital PA embedded in EHR systems to comply with evolving CMS requirements and reduce administrative burden.