01MULTIPLE EFFECTIVE DATES - Immediate review required:
By October 1, 2026: Billing team must update Medicaid billing protocols to require modifier 25 when billing eligible E&M (Evaluation & Management) services with XXX-status procedures.
02Update billing software validation rules and provider education materials.
03Claims submitted without proper modifier 25 application will be denied.
04By December 1, 2026.
05Stop billing blood product administration services separately under Medicaid.
06Consolidate into primary procedure billing.
07Update all charge capture systems and billing templates.
08Implement new combined reimbursement policy for modifiers 90 and 91 for laboratory services across Medicare Advantage and Medicaid.
09Update billing software to recognize new modifier guidelines.
10Prepare and implement treatment room reimbursement updates for Medicaid.
11Verify facility coding changes in billing system.
12Test workflows before effective date.
13Before October 1, 2026: Billing team must review and implement Excludes1 note updates for Commercial plans to prevent claim denials.
14Immediate (Ongoing): Implement Carelon Medical Benefits Management updates effective September 28, 2026 (Medicare Advantage) and November 28, 2026 (Medicaid).
15Prior authorization and clinical appropriateness guideline changes require system updates.
16Review precertification/prior authorization requirement changes for Medicare Advantage effective September 28, 2026.
17By January 1, 2027: Ensure all Medicaid claim processing systems account for new 2027 work requirement rules and documentation needs.
18Other Administrative: Front desk and credentialing staff should utilize new Quick Contact Guide and Availity Essentials provider enrollment features.
19Complete required 2026 consumer grievance and appeals attestation survey for Commercial plans.