[New York] September 2026 Provider Newsletter

REQUIREMENTS - 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. Update encounter forms and provider education materials. Non-compliance will result in claim denials. - Review and implement updated claims editing process for outpatient facility claims in billing software. Contact Anthem at the provided support line if unclear on new editing rules. By October 1, 2026 (Commercial): - Implement new combined reimbursement policy for Moderate (Conscious) Sedation covering both professional and facility components. Update fee schedules and billing guidance. Verify anesthesia billing protocols reflect new policy. By December 1, 2026 (Medicare Advantage and Medicaid): - Implement new combined reimbursement policy for modifiers 90 and 91 for laboratory services. Update billing software to apply correct modifiers and reimbursement rates. Train billing staff on proper usage of modifiers for laboratory claims. - Implement facility guidelines updates for claims related to professional services for Commercial plans. Update facility billing protocols and claim submission rules. - Implement prior authorization and step therapy updates for medications billed under the medical benefit (Medicaid). Update prior auth triggers in billing system. Notify prescribers of new requirements. - Implement specialty pharmacy updates (Commercial). Verify pharmacy claim routing and prior auth processes. By December 1, 2026 (Commercial and Medicare Advantage): - Update prior authorization requirement lists per Carelon Medical Benefits Management. Implement new precertification/prior auth triggers in billing system for both plan types. By November 15, 2026 (Medicare Advantage): - Update clinical appropriateness guidelines from Carelon Medical Benefits Management. Review prior authorization criteria and update system rules accordingly. Before January 1, 2027 (Medicaid): - Educate all providers on new Medicaid 2027 work requirements effective January 1, 2027. Ensure patient eligibility verification processes account for work requirement rules. Immediate/Ongoing: - Billing team should enroll with Availity Essentials if not already done to access professional provider enrollment welcome letters and new Quick Contact Guide. - All staff should reference new Quick Contact Guide for faster support access across all plan types (Commercial, Medicare Advantage, Medicaid).