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[New York] September 2026 Provider Newsletter
Effective date
Not stated in the notice
Identified
Sep 2, 2026
Summary
This September 2026 New York provider newsletter contains multiple policy updates across administrative, clinical, reimbursement, and prior authorization areas, with multiple effective dates ranging from October 1, 2026 through January 1, 2027. Key changes include new modifier 25 billing requirements for Medicaid (effective October 1, 2026), updated claims editing for outpatient facilities (effective October 1, 2026), new reimbursement policies for moderate sedation and laboratory service modifiers (effective October 1 and December 1, 2026), and Medicaid 2027 work requirements (effective January 1, 2027).
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What to do
Action · 26 steps
01REQUIREMENTS - Multiple effective dates require phased implementation:
By October 1, 2026 (Medicaid):
- Billing team must update billing system rules to require modifier 25 when billing eligible E&M services with XXX procedures on the same date of service.
02Update encounter forms and provider education materials.
03Non-compliance will result in claim denials.
04- Review and implement updated claims editing process for outpatient facility claims in billing software.
05Contact Anthem at the provided support line if unclear on new editing rules.
06By October 1, 2026 (Commercial):
- Implement new combined reimbursement policy for Moderate (Conscious) Sedation covering both professional and facility components.
07Update fee schedules and billing guidance.
08Verify anesthesia billing protocols reflect new policy.
09By December 1, 2026 (Medicare Advantage and Medicaid):
- Implement new combined reimbursement policy for modifiers 90 and 91 for laboratory services.
10Update billing software to apply correct modifiers and reimbursement rates.
11Train billing staff on proper usage of modifiers for laboratory claims.
12- Implement facility guidelines updates for claims related to professional services for Commercial plans.
13Update facility billing protocols and claim submission rules.
14- Implement prior authorization and step therapy updates for medications billed under the medical benefit (Medicaid).
15Update prior auth triggers in billing system.
16Notify prescribers of new requirements.
17- Implement specialty pharmacy updates (Commercial).
18Verify pharmacy claim routing and prior auth processes.
19By December 1, 2026 (Commercial and Medicare Advantage):
- Update prior authorization requirement lists per Carelon Medical Benefits Management.
20Implement new precertification/prior auth triggers in billing system for both plan types.
21By November 15, 2026 (Medicare Advantage):
- Update clinical appropriateness guidelines from Carelon Medical Benefits Management.
22Review prior authorization criteria and update system rules accordingly.
23Before January 1, 2027 (Medicaid):
- Educate all providers on new Medicaid 2027 work requirements effective January 1, 2027.
24Ensure patient eligibility verification processes account for work requirement rules.
25Immediate/Ongoing:
- Billing team should enroll with Availity Essentials if not already done to access professional provider enrollment welcome letters and new Quick Contact Guide.
26- All staff should reference new Quick Contact Guide for faster support access across all plan types (Commercial, Medicare Advantage, Medicaid).
Codes mentioned
259091
Original notice
[New York] September 2026 Provider Newsletter
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[Virginia] September 2026 Provider NewsletterHighNo effective date · Newsletter[Ohio] September 2026 Provider NewsletterHighNo effective date · Newsletter[California] September 2026 Provider NewsletterHighNo effective date · Newsletter[Ohio] New combined reimbursement policy: Modifiers 90 and 91: Laboratory ServicesHighEffective Dec 1, 2026 · Claims & BillingBrowse every Anthem BCBS change in the policy list